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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701003
Report Date: 07/29/2024
Date Signed: 07/29/2024 11:09:31 AM


Document Has Been Signed on 07/29/2024 11:09 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 LEGACY ELDERLY CAREFACILITY NUMBER:
342701003
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:1986 LEFORD WAYTELEPHONE:
(916) 629-9225
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY:6CENSUS: 5DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Kimberly SloanTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA met with facility staff Kimberly Sloan, and explained the purpose of the visit. Administrator Diana was contacted via phone and arrived later during the visit.

LPA and facility staff toured the physical plant to ensure compliance with Title 22 regulations. LPA observed resident bedrooms to be clean and free from odors. Staff bedroom was observed to be clean and fully furnished. Water temperature reads 105° F in the bathroom and room temperature reads 73° F. LPA observed the facility to have adequate food supply. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher had a last check on 05/24/2024. Medications, sharps, and toxins were locked away and inaccessible to residents in care. No emergency exits were observed to be obstructed.

Residents were observed eating breakfast, which was waffles, sausage, scrambled eggs, and coffee, watching the Olympic games on television, playing solitaire, and completing ADLs. Staff was observed cleaning the facility, preparing meals, completing chart documentation, and engaging with the residents.

LPA Valerio reviewed two (2) staff and three (3) resident files. Resident files were observed to be complete with required annual documentation and care plans. Staff files were observed to be complete The last emergency drill was conducted on 05/20/2024.

LPA Valerio requested the following annual documentation be sent by 08/02/2024: LIC 500, LIC 308, LIC 610, and copy of Liability Insurance

Per California Code of Regulations (CCR) - Title 22, no deficiencies were observed during today's visit. An exit interview was held, and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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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