<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701093
Report Date: 11/19/2021
Date Signed: 11/19/2021 11:08:39 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:GOLDEN MOMENTS CARE HOMEFACILITY NUMBER:
342701093
ADMINISTRATOR:WHITE, MAKAYLAFACILITY TYPE:
740
ADDRESS:2651 ARMSTRONG DRTELEPHONE:
(916) 489-2578
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 6DATE:
11/19/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Makayla WhiteTIME COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On November 19, 2021 at 10:10am Licensing Program Analyst (LPA) Chris Hopkins arrived at Golden Moments Care Home for the purpose of conducting an unannounced Pre-Licensing inspection. LPA was screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility. LPA met with Administrator Makayla White and together conducted a tour of the home. Licensee Mark Graham showed up at a later time.

LPA inspected the kitchen, resident bedrooms, resident bathroom, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 110 degrees F which meets the 105-120 degree Fahrenheit regulation. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications locked. Cleaning supplies kept locked in kitchen cabinet. LPA observed a sufficient supply of towels and linens able to meet the needs of the residents. The facility has an approved LIC 808 mitigation plan on file and uploaded into FAS.

The facility currently has 6 residents residing at the home at this time.


LPA reviewed the Component III orientation with Administrator and Licensee. Component III orientation successfully completed.

LPA recommends moving forward with licensure. Exit interview was conducted and a copy of report provided to facility representative.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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 1