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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700512
Report Date: 03/19/2024
Date Signed: 03/19/2024 12:15:22 PM


Document Has Been Signed on 03/19/2024 12:15 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:
03/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Russel Romero & Jero NinoblaTIME COMPLETED:
12:10 PM
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On 3/19/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. LPA met with Administrator Russel Romero and explained the purpose of the visit.

During this visit, LPA and Administrator discussed staffing concerns as LPA was informed former caregivers had resigned due to change of shift hours. LPA was informed there are two caregivers per shift for AM and PM, the one caregiver for NOC. LPA was informed staff from sister facility also assist with caregiving shifts. LPA requested a copy of LIC 500 to thoroughly list what day each caregiver works.

Exit interview and a copy of report provided via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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