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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 08/05/2024
Date Signed: 08/05/2024 04:13:29 PM

Document Has Been Signed on 08/05/2024 04:13 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 LEGACY ELDERLY CARE IIFACILITY NUMBER:
342701152
ADMINISTRATOR/
DIRECTOR:		LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 5DATE:
08/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Mareta TekuTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams spoke with licensee Diana Garcia over the phone and explained the purpose of the visit.

During a prior visit, LPAs Moleski and Williams observed two backyard sheds, which have not been permitted for habitation and which have not been cleared by the fire department. During the visit, one of the sheds had an air conditioning unit running, but the windows were blocked. LPAs Moleski and Williams observed through the windows of the second shed personal affects, including food and medications, along with a pet cat. LPAs Moleski and Williams knocked on both sheds but received no answer. In an interview, Garcia said she and her mother had used and were still using the sheds for habitation on occasion.

During this visit, LPAs Moleski and Williams observed a sewer outflow pipe which had spewed out toilet paper and feces at some previous time. The toilet paper and feces were dried up and caked onto the cement patio. A staff member (S1) said that the toilet paper and feces had been there for at least two weeks.

This facility is being cited per 22 CCR Sections 87303(a) and 87204(a). An exit interview was held with Garcia. Appeal rights and a copy of this report were left with staff member Mareta Teku.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2024 04:13 PM - It Cannot Be Edited


Created By: Vincent Moleski On 08/05/2024 at 04:00 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2024
Section Cited
CCR
87303(a)

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"(a) The facility shall be clean, safe, sanitary and in good repair at all times..." This requirement was not met as evidenced by:
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Licensee agrees to have the area cleaned by POC due date. Licensee shall send a photograph of the cleaned area by POC due date.
vincent.moleski@dss.ca.gov
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Based on observation, dried feces and toilet paper were left on a backyard patio, which poses an immediate health and safety risk.
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Type A
08/06/2024
Section Cited
CCR87204(a)

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"A licensee shall not operate a facility beyond the conditions and limitations specified on the license..." This requirement was not met as evidenced by:
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Licensee agrees to send LPA Moleski a written plan to address this deficiency by POC due date.
vincent.moleski@dss.ca.gov
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Based on interview and observation, two backyard studios were being used for habitation, despite not being approved for use by the fire department, code enforcement, and this facility's license.
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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 Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024


LIC809 (FAS) - (06/04)
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