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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700512
Report Date: 01/23/2023
Date Signed: 01/23/2023 04:59:08 PM


Document Has Been Signed on 01/23/2023 04:59 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
CHICO - RESIDENTIAL, 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: 4DATE:
01/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Oliver FuleTIME COMPLETED:
05:00 PM
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On 01/23/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Required- 1 Year annual. LPA met with Administrator, Oliver Fule, and explained the purpose of the visit. Prior to today's inspection, LPA ensured she applied hand sanitizer and the following Personal Protective Equipment (PPE) was worn: surgical mask. The facility currently has (4) residents and (0) resident on hospice services. .

LPA and Administrator toured the interior of the facility including the common room, kitchen, bathrooms and residents bedrooms. LPA observed (1) resident to be in the common area, and (1) residents to be in his private room. LPA observed two (2) resident rooms to be shut with the resident inside. In the areas toured, no immediate health and safety risk were observed. LPA observed the facility to have 2+ days of perishables and 7+ days of non-perishables foods. Administrator further explained to LPA there are extra food in the next door facility as it is used for storage.

LPA observed the facility to have documentation of visitation screening. LPA observed the facility to have the Ombudsman and CCLD posters to be posted in the hallway. LPA observed paper towels, soap and hand washing signs in bathroom. LPA observed the facility to have COVID-19 signs to be posted throughout the facility. LPA observed sharps, toxics and medication to be locked and secured. LPA and Administrator completed the infection control domain together, and at this time the facility was found to be at substantial compliance.

At this time, LPA requested a copy of liability insurance, Administrator Certificate, LIC 308, and LIC 500 to be submitted to LPA by Friday February 3, 2023.

Exit interview was conducted. A copy of report was left at facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
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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