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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700512
Report Date: 02/16/2024
Date Signed: 02/16/2024 04:18:41 PM


Document Has Been Signed on 02/16/2024 04:18 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLDEN RETREAT SENIOR LIVING 1FACILITY NUMBER:
342700512
ADMINISTRATOR:FULE, OLIVERFACILITY TYPE:
740
ADDRESS:3425 PALESTINE LNTELEPHONE:
(916) 482-5507
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
02/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Oliver FuleTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding an incident report the Department received. LPA met with Administrator and explained the purpose of the visit.

Administrator informed LPA that last month, R1's family member came to the facility unannounced. When asked if visitation was scheduled as ordered in a family court, R1's family member started yelling at staff and allegedly attempted to kick the glass door opened. Administrator reported local law enforcement was contacted. Administrator reported no further issues since this incident.

Administrator reported residents were in the their private rooms and did not witness this encounter. Administrator reported no residents was in distress.

Exit interview conducted and a copy of report was emailed.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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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