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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 11/06/2024
Date Signed: 11/06/2024 02:44:23 PM

Document Has Been Signed on 11/06/2024 02:44 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:
11/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Misivono QadrokaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Holly Williams and Licensing Program Manager Czarrina Camilon-Lee arrived unannounced for this complaint investigation. LPA Williams and LPM Camilon-Lee met with caregiver Misivono Qadroka and explained the purpose of the visit. The administrator Diane Garcia was asked to come to the facility but declined and asked if Garcia could call.

During an interview with R3 LPA Williams found unlocked medications In resident night stand drawer accessible to anyone: Robitussin cough medicine and acid rescue.

The following deficiencies cited. See LIC809-D. Appeal rights provided.

This investigation consisted of record review and interviews with staff and residents. LPA Williams interviewed (R1-R4) and did record review for R3, R4, R2.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 02:44 PM - It Cannot Be Edited


Created By: Holly Williams On 11/06/2024 at 02:21 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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2024
Section Cited
CCR
87465(h)(2)

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87465Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible ...
This requirement was not met as evidenced by:
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Staff agreed to lock up the medicines today. Administrator Diane Garcia will send a statement of understanding stating that the regulations have been reviewed and staff has been retrained on medication storage by POC due date. Holly.williams@dss.ca.gov
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Based on observation of LPA Williams and LPM Camilon-Lee medications were observed unlocked in night stand drawer which poses an immediate 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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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