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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 04/13/2023
Date Signed: 04/13/2023 12:24:38 PM

Document Has Been Signed on 04/13/2023 12:24 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: 6DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kohata Qalo TIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 04/13/2023 at 8:30 AM. LPA met with Kohata Qalo and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for six non-ambulatory residents. There are currently six residents who reside at this facility. The facility has an approved hospice waiver for one resident.

LPA Martinez toured the facility with Kohata Qalo on 04/13/2023 at 11:00 AM.

LPA Martinez reviewed six out of six resident files, and the files were up to date. LPA Martinez reviewed four out of four staff files, and the files were up to date. LPA Martinez reviewed 2 out of 6 residents' Medication Administration Records (MAR). Resident 3 (R3) was missing a doctor's order for PRN Medication Acetaminophen 300 MG. In addition, Gabapentin 300 MG medication order label was altered with a black marker. Staff 1 also reported they altered the Gabapentin administration order label.

In addition, March and April 2023 MAR states Gabapentin take 25 MG: 1 capsule by mouth 3 times per day. January 2023 MAR states Gabapentin 300 MG take 2 capsules 3 times per day. As a result, the facility will need to obtain an updated doctor's order for Gabapentin and correct April MAR. Resident 5 (R5) MAR was up to date.

Continued...

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 04/13/2023 12:24 PM - It Cannot Be Edited


Created By: Avelina Martinez On 04/13/2023 at 10:15 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: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
87465(e) Incidental Medical and Dental Care For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and file review, the Licensee did not ensure resident 3 had a PRN doctors order for their Acetaminophen 500 MG. This posed a potential health and safety risk to resident 3
POC Due Date: 04/27/2023
Plan of Correction
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Facility staff agrees to conduct Incidental Medical and Dental Care for all facility staff. In addition, the facility staff agrees to obtain a doctors order for the Acetaminophen 500 MG and file in R3's medication file. All training documents and doctors orders shall be emailed to LPA Martinez by POC date 04/27/2023 5 PM.
Type B
Section Cited
CCR
87465(h)(4)
87465(h)(4) Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and file review, resident 3's Medication bottle label was altered. The doctors administration order information was altered with a black marker.
POC Due Date: 04/27/2023
Plan of Correction
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Facility staff agrees to conduct Incidental Medical and Dental Care training for all staff. In addition, facility staff agreed to obtained a doctors order for Gabapentin 300 MG, and obtain a bottle with the correct medication order label. All training documents, medication orders, and medication bottle picture shall be emailed to LPA Martinez by POC Date 04/27/2023 by 5PM
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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


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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
VISIT DATE: 04/13/2023
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During the tour, it was observed R3 was residing in a non-designated resident room. Per License posted at Facility and per Fire Clearance form STD 850 Bedrooms four and five are not permitted for client use. The facility sketch will need to be updated, and bedroom change arrangements need to be implemented for R3.

An immediate civil penalty was assessed on April 13, 2023 in the amount of $500.00 for fire clearance violation Title 22 regulation Fire Safety 87203.

The facility smoke detectors, carbon detectors, and fire extinguishers are in good repair. Last fire drill was conducted in February 2023. The facility has a first aid kit. The facility common areas and resident bedrooms were furnished and in good repair. The facility bathrooms were sanitary, and water temperature measured at 106 degrees. The facility temperature measured at 75 degrees. The facility had an adequate food supply, and the kitchen was sanitary. The exterior of the home was maintained, and the emergency exit gate was clear of debris.

As a result of this annual inspection, deficiencies can be found on the 809-D page. An exit interview was conducted, and copy of this report was provided to the facility. Also, a copy of the appeals rights document was provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 04/13/2023 12:24 PM - It Cannot Be Edited


Created By: Avelina Martinez On 04/13/2023 at 11:48 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: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation resident 3 was residing in a non-designated resident room.
POC Due Date: 04/14/2023
Plan of Correction
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Facility staff agrees to make room change arrangement plans and update facility sketch by POC date 04/14/2023. Facility staff shall email LPA Martinez room change plans and updated facility sketch by POC date 04/14/2023 5PM.
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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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