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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700884
Report Date: 05/17/2024
Date Signed: 05/17/2024 09:39:39 AM

Document Has Been Signed on 05/17/2024 09:39 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:GOLDENLIFE CARE HOMEFACILITY NUMBER:
342700884
ADMINISTRATOR/
DIRECTOR:		HAAMANKULI, BBWAANIFACILITY TYPE:
735
ADDRESS:18 ENGLISH IVY COURTTELEPHONE:
(916) 692-8201
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY: 4CENSUS: 4DATE:
05/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:HAAMANKULI, BBWAANITIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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On 5/17/24 at 9:00am, Licensing Program Analyst (LPA) made an unannounced Case Management inspection to address an incident report received by the department in February 2024. LPA met with the Licensee and discussed the reported incident report.

LPA conducted staff interviews with two staff members. There were no residents present to interview.
Additional interviews will be conducted to gather additional information of the reported incident. LPA reviewed R1's file and IPP. LPA observed a medical appointment on 2/28/24 for R1.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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