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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701175
Report Date: 07/05/2023
Date Signed: 07/05/2023 11:25:28 AM


Document Has Been Signed on 07/05/2023 11:25 AM - 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 III ELDERLY CAREFACILITY NUMBER:
342701175
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:7695 RIVER VILLAGE DRTELEPHONE:
(916) 400-4098
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 3DATE:
07/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Diana GarciaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/5/23 at 9:00am and met with Isikeli Tuikenatabua, Caregiver and stated the purpose of the visit. Isikeli Tuikenatabua contacted the Administrator Diana Garcia regarding todays visit. The Administrator arrived within 15 minutes to assist with todays visit. This visit is to conduct a Required - 1 Year inspection. LPA was allowed entry into the home that is licensed for a capacity of 6 non-ambulatory residents. Caregiver, Isikeli Tuikenatabua is finger print cleared and associated to the facility. License fees are current. Hospice waiver granted for 1 resident to receive hospice care services. Administrator certificate expired 1/3/2023. Although the Department is in receipt of pertinent documentation and fee for renewal, the updated certificate has not been received by the Administrator yet.

LPA and Diana Garcia toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed there are 2 residents in the home and 1 out in the community during this visit. LPA observed the kitchen area, dining area, bedrooms, bathrooms, storage areas, garage, and laundry room. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 106.6*F which is within the required range of 105-120*F. The temperature inside the facility measured at 74*F which is within the required range of 68-85*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) and exit alarms on every door in the home. Facility has central heating and air. LPA observed 1 staff and 3 resident files and conducted interviews during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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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