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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701093
Report Date: 12/04/2024
Date Signed: 12/04/2024 01:52:33 PM

Document Has Been Signed on 12/04/2024 01:52 PM - 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 MOMENTS CARE HOMEFACILITY NUMBER:
342701093
ADMINISTRATOR/
DIRECTOR:		ANDERSON-WHITE, MAKAYLAFACILITY TYPE:
740
ADDRESS:2651 ARMSTRONG DRTELEPHONE:
(916) 979-9828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY: 6CENSUS: 6DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Makayla WhiteTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/4/24 at 11:15AM to conduct a Required - 1 Year annual inspection visit. LPA met with Makayla White, Administrator and explained the purpose of the visit.

The facility is licensed for a capacity of 6 non-ambulatory residents in rooms 1, 2, and 3. Hospice approved for 6 residents of which there are 0 residents receiving hospice care services during this visit. Licensing fees are current. Administrator certificate expires 3/11/2025 for Makayla White.

LPA observed an Infection Control Plan during this visit. LPA observed residents participating in group and individual activities during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, 3 bedrooms and 2 bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The most recent emergency drill was conducted on 7/23/24.

The temperature inside the facility was observed to be at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 118.4*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.

LPA reviewed 3 staff and 3 resident files during this visit.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN MOMENTS CARE HOME
FACILITY NUMBER: 342701093
VISIT DATE: 12/04/2024
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Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees-Current
Criminal Record Clearances LIS536-Current
Administrative Organization LIC309-Current
Designation of Administrative Responsibility LIC308-Submit
Personnel Report LIC500-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-NA
Surety Bond LIC402-NA
Facility Floor Plan/Plot Plan LIC999-Current
Fire Clearance (consistent with terms and limitations of license)-NA
Qualifications of Administrator/Facility Manager-Submit
Articles of Incorporation/Organization, Constitution and bylaws-NA
Partnership Agreement-NA
Control of Property-NA
Emergency Disaster Plan LIC610-Submit
Plan of Operation (Restricted Health Care Plan)-NA
Admission Policies and Procedures-NA
Health Screening Report-Facility Personnel LIC503-NA
Bacteriological Analysis of Private Water Supply-NA
In-service Training Program-NA
Medication Procedures-NA
Transportation Procedures-NA
Job Description/Personnel Policies-NA
Exemptions/Waivers and Exceptions-Current
First aid/CPR certificates-Current
Liability Insurance-(if applicable)Submit
Infection Control Plan-Submit if applicable

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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