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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701003
Report Date: 08/31/2022
Date Signed: 08/31/2022 10:59:54 AM


Document Has Been Signed on 08/31/2022 10:59 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GOLDEN LEGACY ELDERLY CAREFACILITY NUMBER:
342701003
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:1986 LEFORD WAYTELEPHONE:
(916) 629-9030
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY:6CENSUS: 5DATE:
08/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Gloria BaileyTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived unannounced to conduct a Required - Annual visit on 08/31/2022 at 10:00 AM. Administrator Certificate for Diane Garcia expires 01/03/2023. LPA met with Gloria Bailey regarding the purpose of todays visit. Gloria contacted the Administrator Diane Garcia whom arrived 30 minutes after LPA's arrival. The facility is licensed for 6 non ambulatory, there are 5 residents present today.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed residents during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 105.5*F which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents.
The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Liability Insurance
Personnel Report (LIC500)
Administrator Certificate

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted. A copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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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