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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 09/19/2024
Date Signed: 09/19/2024 03:09:36 PM

Document Has Been Signed on 09/19/2024 03:09 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: 4DATE:
09/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Diana GarciaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open a complaint investigation and observed unrelated deficiencies. LPAs Moleski and Williams spoke with facility administrator Diana Garcia on the telephone and explained the purpose of the visit. Garcia said staff member Misivono Qadroka could sign this report in her absence.

Upon arrival, LPAs Moleski and Williams observed a caregiver present in the facility (S1). LPA Williams reviewed Guardian records and observed S1 was not associated to this facility. S1 told LPA Moleski that they had been working at this facility since 9/1/24, and works five days per week. LPAs Moleski and Williams reviewed S1's file and observed that it was not complete. S1's personnel record (LIC 501) was not completed, did not include S1's educational history or past work experience, and was not signed by S1.

This facility is hereby cited per 22 CCR Sections 87355(e)(2) and 87412(a). An exit interview was held with Garcia. Appeal rights and a copy of this report were left with Qadroka.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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 09/19/2024 03:09 PM - It Cannot Be Edited


Created By: Holly Williams On 09/19/2024 at 01:46 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: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2024
Section Cited
CCR
87355(e)(2)

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"(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...

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)..."
This requirement was not met as evidenced by:
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Licensee agrees to associate S1 by POC due date. Holly.williams@dss.ca.gov
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Based on observation, record review, and interview S1 was not associated with the facility which poses an immediate health, safety and/or personnel rights risk.
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Type B
09/23/2024
Section Cited
CCR87412(a)

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"87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information..."

This requirement was not met as evidenced by:
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Licensee agrees to have personnel record completed by POC due date. Holly.williams@dss.ca.gov
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Based on record review, S1 did not have a completed personnel record which poses a potential health, safety, and/or personnel rights risk.
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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:Holly Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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