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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:12:17 PM


Document Has Been Signed on 04/11/2024 12:12 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIFACILITY NUMBER:
342701152
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:MORIA GAUNAVOU - DIRECT CARE STAFFTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection. LPA met with direct care staff and explained purpose of visit. Administrator's Certification 1/3/2025.

LPA and direct care staff toured the interior and exterior of the facility including common areas, resident bedrooms, resident bathrooms, staff room, kitchen, dining room, laundry area, and garage. LPA observed the facility to be clean and in good repair and to have sufficient furniture and lighting throughout. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA observed locked sharps locked cabinet designated for medications. Chemicals (2 bottles of bleach and 1 gallon of bug spray) are not locked up in back area of property. LPA observed grab bars and non-skid flooring in all bathrooms. LPA observed locked toxins in the laundry room and a supply of linens/towels/blankets on hand. Fire extinguishers was last inspected 2/28/2024. The facility conducts fire/disaster drills with residents on 2/9/2024. Smoke/monoxide alarms are working order. LPA observed a complete First Aid kit on site and measured the hot water at 113.2 *F in the bathroom. LPA observed all doors to have alarms. LPA observed seating on patio, a locked shed, and two gates that were unlocked and accessible. There were tree branches and debris in back of property. Workshop was locked with a cat looking out. Facility sketch shows workshop, but licensee stated mom stays there occasionally. Two old refrigerators, two washers, and two dryers which need to be removed. LPA reviewed five resident files and three staff files, including criminal record clearances. A review of staff records indicates not all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

LPA requested the following updated documents for community care licensing to be submitted via email by April 16, 2024: Updated Facility Sketch, New Fire Clearance, LIC 308 Designation of Administrator, LIC 500 - Personnel Report, LIC 610E Emergency Disaster Plan, Copy of Administrator's Certificate, and Copy of Liability Insurance. ruth.wallace@dss.ca.gov

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies are being cited. See 809-D's for citations. Immediate civil penalty of $500.00 was issued to facility. Failure to correct the deficiencies by the noted due date may result in an additional penalty being assessed.
Exit interview conducted with direct care staff. Copy of reports and (LIC 811 Confidential Names) left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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 4


Document Has Been Signed on 04/11/2024 12:12 PM - It Cannot Be Edited

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: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in workshop in backyard does not have fire clearance and individuals have been living there which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Licensee agrees to submit plan of correction stating no individuals will live in workshop until fire clearance has been approved and submitted to community care licensing. POC is due on 4/12/24 and will be submitted to LPA via email. ruth.wallace@dss.ca.gov
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in there were two bottles of bleach, two bottles of detergent, and a gallon of bug spray on old washing machine near back fence which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Licencess agreed to immediately lock up all chemicals and LPA observed them being locked up on 4/11/2024. No further action required.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/11/2024 12:12 PM - It Cannot Be Edited

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: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above in licensee's mom is not fingerprint cleared and has been staying in workshop in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Licensee agrees to submit plan of correction by 4/12/24 stated all individuals subject to a criminal record review shall be fingerprinted prior to working, residing or volunteering in a licensed facility. Licensee will submitt POC via email to LPA. ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/11/2024 12:12 PM - It Cannot Be Edited

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: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in tree branches, two washing machines, two dryers, two refrigerators, and old lumber was piled in backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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Licensee agrees to submit plan of correction by 4/16/2024. Licensee will remove tree branches, two washing machines, two dryers, two refrigerators, and old lumber by POC date. Licensee agrees to submit pictures of cleared area in backyard to LPA. ruth.wallace@dss.ca.gov
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in workshop has been used for living quarters which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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Licensee agrees to submit plan of correction by 4/16/2024 stating intention for workshop. If it is to be used for living quarters licensee shall obtain building permits and alterations to community care licensing. In addition, a new fire clearance and facility sketch would need to be completed. Licensee agrees to submit to LPA via email. ruth.wallace@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4