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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700800
Report Date: 09/18/2023
Date Signed: 09/22/2023 09:08:52 AM


Document Has Been Signed on 09/22/2023 09:08 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLDEN HOME FOR SENIORSFACILITY NUMBER:
342700800
ADMINISTRATOR:TOLON, MA MAGNOLIA MFACILITY TYPE:
740
ADDRESS:8701 MILO COURTTELEPHONE:
(916) 686-2129
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:MA MAGNOLIA TOLONTIME COMPLETED:
03:30 PM
NARRATIVE
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On 9/18/23 at approximately 10am Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Ma Magnolia Tolon and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 6 bedrooms and 5 bathrooms for resident use. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 1 ambulatory resident and 5 non ambulatory residents.

Facility Observation: Upon entry the residents were in the common area or in their rooms watching tv or on personal devices. Staff checked in with residents every 20- 30 minutes. Lunch was served at the kitchen table or in resident rooms. The lunch menu was beef with potatoes and fruit. 2 families visited residents in the morning. LPA observed staff working with residents on their physical therapy.

During this inspection 6 resident files and 2 staffing files were reviewed for regulatory compliance.
Staff files contained required contents including staff training requirements.

3 of 6 Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility has 1 resident with half bedrails with physician orders in place.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN HOME FOR SENIORS
FACILITY NUMBER: 342700800
VISIT DATE: 09/18/2023
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Water temperature in common bathroom reads 124.5F* with “caution hot water” signs in place. Temperature on the heating and air unit read 77*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. Fire extinguisher was serviced 5/15/23. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. Facility conducts quarterly fire drills.

LPA requested and received an updated copy of LIC 308, 309, 610E and LIC 500.

The facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Ma Magnolia Tolon, and a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/22/2023 09:08 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GOLDEN HOME FOR SENIORS
FACILITY NUMBER: 342700800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87623(a)(1)(A)


(A) Irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders.
This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on record review and interview R(1) has a catheter. Administrator states training in catheter care has occurred but was not documented .This poses an immediate risk to residents in care.
POC Due Date: 09/19/2023
Plan of Correction
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POC Licensee states she will request an exception for catheter by POC date of correction. Request will be emailed to LPA Fain at jennifer.fain@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/22/2023 09:08 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GOLDEN HOME FOR SENIORS
FACILITY NUMBER: 342700800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review and interview the administrator did not ensure that all required documents were updated and available in 3 of 6 resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator states files will be updated and missing items will be emailed to LPA at jennifer.fain@dss.ca.gov by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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3
4
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4