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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:58:38 PM

Document Has Been Signed on 05/24/2023 12:58 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: 6DATE:
05/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Diana Garcia TIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 05/24/2023 at 10:30 AM to conduct a case management visit. LPA met with Nadine Mills and Diana Garcia and explained the purpose of the visit.

The purpose of the visit is to follow up on resident's 1 (R1) care plan and relocation plan. During case management visit LPA Martinez reviewed R1's facility files. It was learned R1 is a double amputee and requires a hoyer lift to be transferred to and from wheelchair and on and off hospital bed. In addition, R1 requires two persons to complete hoyer lift transfers. Moreover, R1 is not able to access their wheelchair because their wheelchair/hoyer sling is not the correct length. At this time, R1 is not able to transfer onto their wheelchair safely. Additionally, R1's assessment needs to be updated to reflect hoyer lift use. As a result, facility staff agreed to complete a reassessment, and obtained the proper equipment for transfers and wheelchair use. Moreover, at this time, R1 is able to turn and reposition in bed independently; however, if this changes, the facility was advised they would need a bedridden fire clearance approval.

Furthermore, facility sketch will need to be updated. In addition LPA Martinez observed staff residing in a room that has not been designated as a staff room on the fire clearance STD 850 form. The home owner constructed a wall in the middle of room 4 to create an additional room. However, the wall is not complete and obstructs a window from opening. LPA Martinez will follow up with Sacramento Fire Department in regards to rooms 4 and 5. LPA will conduct a Case Management visit at another time to follow up on Fire Clearance regulations.

Due to this visit, deficiencies were cited and can be found on the 809-D page. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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 05/24/2023 12:58 PM - It Cannot Be Edited


Created By: Avelina Martinez On 05/24/2023 at 12:25 PM
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: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
CCR
87463(a)

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87463(a) Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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Facility staff agrees to complete a reappraisal for R1 by POC date 05/31/2023. Reappraisal will include hoyer lift. Reappraisal will be emailed to LPA Martinez by POC Date 05/31/2023 by 5 PM. Facility staff also agrees to assist with finding a new placement for R1.
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This requirement was not met as evidence by: based on file review, the Licensee did not ensure to complete a reappraisal for R1 which includes hoyer lift need. This posed a potential health safety risk to R1.
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Placement plan shall be emailed to LPA Martinez by POC date 05/31/2023 by 5 PM.
Type B
05/31/2023
Section Cited
CCR87464(d)

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87464(d) Basic Services A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs... This requirement was not met as evidence by: Based on observation,
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Facility staff agrees to assist R1 with transfers and obtained a hoyer sling for R1 by POC date 05/31/2023. In addition facility staff agrees to implement a transfer care plan for R1 and assist R1 with repositioning and transfers.
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interviews, and file review, the Licensee did not ensure the were able to meet R1's transfer needs. This posed a potential health and safety risk to R1.
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Facility staff agrees to email LPA Martinez repositioning and transfer care plan by POC Date: 05/31/2023 5 PM.
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: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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