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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 12/23/2024
Date Signed: 12/23/2024 01:02:37 PM

Document Has Been Signed on 12/23/2024 01:02 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:
12/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Josevata TuragaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to deliver finding on a complaint and discovered unrelated deficiencies. LPA Williams texted Diana Garcia to inform her of deficiencies found and Garcia stated Josevata Turaga could sign the reports.

LPA Moleski toured a resident's (R1's) room and observed a folding pocketknife with the blade extended alongside antacid tablets and numerous packages of nicotine gum on a small table next to the resident's bed.

This facility is hereby cited per 22 CCR Sections 87465(h)(2) and 87309(a). This facility was previously cited on 11/6/24 for having medications unlocked, including the same kind of antacid tablets. As this is a repeat violation, a civil penalty in the amount of $250 is hereby assessed.

An exit interview was held with Turaga. Appeal rights and a copy of this report were left with Turaga.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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 12/23/2024 01:02 PM - It Cannot Be Edited


Created By: Holly Williams On 12/23/2024 at 12:46 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: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2024
Section Cited
CCR
87309(a)

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"(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients."
This requirement was not met as evidenced by:
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Licensee agrees to remove the knife from the resident's room by the POC due date. Failure to do so will result in additional civil penalties. Licensee shall provide LPA Williams with a photograph of the resident's room showing that all unsafe or hazardous items have been removed.
holly.williams@dss.ca.gov
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Based on observation, a resident was in posession of a knife, which poses an immediate health and safety risk.
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Type A
12/24/2024
Section Cited
CCR87465(h)(2)

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"(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." This requirement was not met as evidenced by:
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Licensee agrees to remove the medication from the resident's room by the POC due date. Failure to do so will result in additional civil penalties. Licensee shall provide LPA Williams with a photograph of the resident's room showing that all unsafe or hazardous items have been removed.
holly.williams@dss.ca.gov
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Based on observation, a resident was allowed access to medication, which poses an immediate health and safety 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: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
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