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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 04:09:57 PM


Document Has Been Signed on 02/16/2024 04:09 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Oliver FuleTIME COMPLETED:
12:05 PM
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On 2/16/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with Administrator, Oliver Fule, and explained the purpose of the visit.

Facility's census is six residents in care which is compliance to licensure.

LPA and Administrator conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: six residents bedrooms, three bathrooms, garage, kitchen, and the common areas.

LPA observed facility to have the mandated posters posted at entrance. LPA observed an active Administrator Certificate posted with facility license. LPA observed medications, sharps, toxins to be locked and inaccessible to residents in care. LPA observed 2+ days of perishable foods. LPA was informed nonperishable foods are stored at their sister facility next door. LPA observed in the kitchen area, the tiles on the counter to be falling off. LPA observed fire extinguisher present with serviced date of 01/26/2023. LPA and Administrator discussed servicing fire extinguishers annually to ensure it is in good working condition.

File review conducted of personnel and residents file.

At this time, LPA is requesting copy of facility liability insurance to be emailed to LPA by Friday February 23, 2023

LPA and Administrator discussed the outstanding licensing fee from 2023 to current. LPA and Administrator completed the CARE tool and deficiencies was observed. Please see LIC809-D.

Exit interview conducted and a copy of the report and appeal rights will be emailed to Administrator.
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)
Page: 1 of 2


Document Has Been Signed on 02/16/2024 04:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 1
FACILITY NUMBER: 342700512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.185(b)(1)(F)
ยง1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture
(b) (1) In addition to fees set forth in subdivision (a), the department shall charge all of the following fees:
(F) A late fee that represents an additional 50 percent of the established current annual fee when a licensee fails to pay the current annual licensing fee on or before the due date as indicated by postmark on the payment.\

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPA observed outstanding balance of $1,237 due to the unpaid 2023 fee plus late fee assessed, which poses a potential health and safety risk for residents in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee is to pay off the outstanding fee and submit proof of payment to LPA by POC due date.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed the kitchen tile counter to be chipped and falling off the surface, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee is to fix the kitchen counter of the facility as it is in disrepair. Submit proof of correction to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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