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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700512
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:39:27 PM


Document Has Been Signed on 03/10/2022 12:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GOLDEN RETREAT SENIOR LIVING 1FACILITY NUMBER:
342700512
ADMINISTRATOR:HOLMQUIST, TRAVIS CFACILITY TYPE:
740
ADDRESS:3425 PALESTINE LNTELEPHONE:
(916) 482-5507
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Oliver Fule, Administrator TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Oliver Fule, Administrator, and explained purpose of inspection. LPA observed caregiver, Gloria Farrow, present also. All staff were wearing a mask. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and was requested to do so also upon entering the facility. The following Personal Protective Equipment (PPE) was worn: KN95 mask. LPA observed (1) resident to be finishing lunch and (4) residents to be napping or watching television in their rooms. There are no residents currently receiving hospice services.

LPA and Administrator toured the interior and observed the facility to ensure the health and safety of residents in care. Areas toured include: common areas,(6) private bedrooms, (3) bathrooms, staff room, kitchen and dining area, family room, and front visiting room. LPA observed the facility to be clean and in good repair and to pose no health and/or safety risk. LPA observed 2+day perishable and 7+day non-perishable food supply. PPE supply for 30+ days on hand. LPA observed various Covid posters throughout, including a hand-washing poster at each sink. Facility to place trash cans with lids in the bathrooms. Fire extinguisher last serviced on 6/1/2021. Inside temperature of 74*. All required postings posted. Discussed vaccination status of residents and staff as well as current visitor protocols and staffing isolation protocols per recent PIN's 22-07 and 22-09 issued in February 2022. Administrator copied PIN 22-09. Discussed updating the visitor sign-in page to include date of vaccination, or negative test result.

There are no deficiencies cited during today's inspection. Exit interview with Administrator, Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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