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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701257
Report Date: 06/06/2023
Date Signed: 06/06/2023 02:19:36 PM

Document Has Been Signed on 06/06/2023 02:19 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 HERITAGE SENIOR CARE IIFACILITY NUMBER:
342701257
ADMINISTRATOR:BIGELOW, YELENAFACILITY TYPE:
740
ADDRESS:3612 EASTERN AVETELEPHONE:
(916) 631-0694
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 5DATE:
06/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Walesi BakararawaTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee arrived unannounced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Avelina Martinez met with Walesi Bakararawa who assisted LPA Martinez in today’s visit.

Facility has a fire clearance for 1 ambulatory resident and 5 non-ambulatory residents. Bedrooms 1, 2, and 3 are permitted for non-ambulatory resident use only. In addition, bedroom 6 is only permitted for ambulatory resident use only. Moreover, rooms 4 and 5 are not permitted for staff or resident use. Rooms 4 and 5 are only permitted for storage use.

The facility staff room number 6 is under construction. LPA Martinez requested a copy of the reconstruction permit on June 06, 2023. LPA Martinez has requested that the permit be emailed to them by June 12, 2023 by 5 PM.

The applicant has not passed the pre-licensing component of the application process. The applicant will correct outstanding issues, and inform LPA Martinez when the corrections have been completed. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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