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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700512
Report Date: 06/28/2023
Date Signed: 07/07/2023 09:16:50 AM


Document Has Been Signed on 07/07/2023 09:16 AM - 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:HOLMQUIST, TRAVIS CFACILITY TYPE:
740
ADDRESS:3425 PALESTINE LNTELEPHONE:
(916) 482-5507
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
06/28/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Travis & Owy HolmquistTIME COMPLETED:
11:30 AM
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An office meeting was held at 10:30AM on 06/28/2023 at the Sacramento North Regional Office virtually via Teams Meeting with Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA), Cassie Yang, Licensee Travis and Owy Holmquist, and facility affiliate, Oliver Fule.

Topics discussed during this meeting were:
· Change in ownership
· Reporting Requirement
· Criminal Background Clearance/Transfers
· Staffing
· PIN 22-24 Home Health/Hospice Agencies Collaboration

The facility will do the following:
· Facility will submit documents to Department to appoint new Administrator to LPA Yang via fax or email by 07/07/2023.
· Facility will submit July 2023 staff schedule to LPA Yang via fax or email by 07/07/2023.
· New applicant will submit application to CAB by 07/05/2023.

At this time, no deficiencies are being cited.

An exit interview and copy of this report will be provided to Licensee via email. A copy will be signed and returned to CCLD by 5:00 PM 06/28/2023.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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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