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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701039
Report Date: 07/30/2021
Date Signed: 07/30/2021 10:42:49 AM

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:A GOLDEN DOVEFACILITY NUMBER:
342701039
ADMINISTRATOR:PUA, ARCELYFACILITY TYPE:
740
ADDRESS:3339 GLENMOOR DR.TELEPHONE:
(916) 541-1534
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:6CENSUS: 0DATE:
07/30/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Arcely Pua and Ronald PuaTIME COMPLETED:
11:00 AM
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On 7/30/21 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted a pre-licensing inspection for A Golden Dove (RCFE). LPA Gould met with Licensee Arcely Pua and Ronald Pua and together conducted the inspection and component 3.

The Licensee is requesting a capacity of six (6) LPA observed the approved fire clearance is for six (6) residents, up to six (6) may be non-ambulatory.

The home is located in a residential area with 6 bedrooms, 2 bathrooms, living room, dining room, kitchen, laundry room, backyard.
Bedroom #1: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. LPA observed a fridge that must be removed before licensure. LPA also observed no linen or bedding on the bed that must be in place before licensure.
Bedroom #2: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. LPA observed the sliding closet door to not be operation and must be repaired prior to licensure.
Bedroom #3: Vacant, to be occupied by two (2) residents. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational.
Bedroom #4: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational.
Bedroom #5: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. LPA observed lights without bulbs that must be installed prior to licensure. LPA also observed a dresser with a broken handle that requires repair.
Bedroom #6 Vacant, to be occupied by caregivers. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational.
Report continued on LIC 9099-C. Page 1 of 2.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: A GOLDEN DOVE
FACILITY NUMBER: 342701039
VISIT DATE: 07/30/2021
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Bathroom #1: LPA and observed bathroom #1 is a full bath equipped with toilet and sink and shower with appropriate grab bars.
Bathroom #2: is a full bath with toilet, sink and roll in shower with appropriate grab bars.

LPA observed adequate seating for residents in the kitchen and an appropriate number of plates, cups and silverware to meet the residents needs. Licensee has an appropriate supply of non-perishable food supply and a 2 day supply of fresh perishable foods. LPA observed the medication storage closet in hallway locked in accordance with Title 22 regulations. LPA also observed sharp knives locked in a drawer in the kitchen and cleaning supplies locked in laundry room. The facility has a working fire extinguisher and fully stocked first aid kit. LPA observed the kitchen range would not light. LPA tested hot water and recorded a temperature of 122 degrees F. which does not meet the 105-120 degree F. regulation. LPA obtained a copy of the facility infection control mitigation plan.

Facility will not transport residents in a facility vehicle or personal vehicle.

At the time of Inspection, the facility is not in compliance with all title 22 regulations and is not approved to be licensed. The following corrections are required prior to being approved for licensure.
  1. Ensure all light fixtures have appropriate light bulbs and are operational.
  2. Remove fridge and broken chair from bedroom #1.
  3. sheets and linen for the bed in Bedroom #1
  4. repair kitchen range so it will light when knobs are turned on.
  5. Remove all hazards from the back yard including but not limited to removing the freezer or making it operational, remove frayed tarp over awning, remove any excess wood, metal debris from the back yard.
  6. ensure all landscaping is complete, LPA observed a large pile of rocks to be used for landscaping in the front driveway
  7. Ensure the sliding closet door in bedroom #2 is operational
  8. ensure broken dresser handle is fixed in bedroom #5
An exit interview was conducted with the licensee and a copy of this report was mailed to the facility for signature.

Page 2 of 2.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2