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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 05/05/2023
Date Signed: 05/05/2023 01:00:28 PM

Document Has Been Signed on 05/05/2023 01:00 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:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 5DATE:
05/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nadine Mills and Charlotte LewisTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 05/05/2023 at 8:30 AM to conduct a case management visit. LPA met with Nadine Mills and Charlotte Lewis and explained the purpose of the visit.

The purpose of the visit is to follow up on learned deficiencies during a complaint investigation 27-AS-20230501151100. The facility did not maintain a current May 2023 Medication Administration Record (MAR) for resident 1 (R1) and resident 2 (R2). In addition, R1's LIC 602 health certification form needs to be updated to reflect R1's physical health status change, and conduct a reappraisal to address R1's special diet needs.

The following deficiencies was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.


An exit interview was conducted, and a copy of this 809 report, 809D page, and appeal rights form were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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
Document Has Been Signed on 05/05/2023 01:00 PM - It Cannot Be Edited


Created By: Avelina Martinez On 05/05/2023 at 11:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2023
Section Cited
CCR
87465(h)(6)

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Incidental Medical and Dental Care 87465(h)(6) The following requirements shall apply to medications which are centrally stored:The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident...This requirement was not met as evidence by
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Facility staff agrees to: conduct a resident file audit by POC Date 05/11/2023. file Audit documentation should be emailed to LPA Martinez by 05/11/2023 by 5 PM.
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Based on observation and file review, the Licensee did not ensure R1 had a current MAR. This posed a potential health and safety risk to R1.
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Type B
05/08/2023
Section Cited
CCR87463(a)

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Reappraisals 87463(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate... This requirement was not met as evidence by. Based on observation, R1's appraisal was not updated to reflect R1's physical health
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Facility staff agrees to incorporate foods that R1 is able to chew. Staff also agrees to conduct a reassessment to include R1's new physical health status changes by POC Date 05/26/2023. Staff will email reassessment to LPA Martinez by POC date 05/26/23 5 PM.
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status change. This posed a potential health and safety risk to R1.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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