342701257-1-11-2024-27-AS-AMAZ-CZDVQU-20240111153855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701257
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:39:05 PM

Document Has Been Signed on 01/11/2024 03:39 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 HERITAGE SENIOR CARE II		FACILITY NUMBER:	342701257
ADMINISTRATOR:	BIGELOW, YELENA		FACILITY TYPE:	740
ADDRESS:	3612 EASTERN AVE		TELEPHONE:	(916) 631-0694
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	6	CENSUS: 5	DATE:	01/11/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Yelena Biglelow		TIME COMPLETED:	03:45 PM

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On January 11, 2024 at 9:00 AM, Licensing Program Analysts (LPAs) Avelina Martinez and Jaime Ivey-Canady arrived unannounced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPAs Martinez and Ivey-Canady met with Yelena Bigelow, who assisted LPAs in today’s inspection.

Facility has a fire clearance for six non- ambulatory residents. Bedrooms 1, 2, 3, and 6 are designated for non-ambulatory resident use only. Bedroom 5 is designated for staff use only. Storage room shall only be used for storage. Facility has an approved hospice waiver for 1. LPS will follow up on Dementia program plan.

Administrator, Yelena Bigelow has been the assigned to the facility. The facility administrator’s certificate expires on 02/01/2025.

LPAs inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. LPAs toured both indoor and outdoors of the facility with Yelena Bigelow on 01/11/2024 at 10:00 AM.

Physical Plant: Based on inspection of the physical plant, Title 22 regulations are not met according to the following: Facility is not sanitary and in disrepair: Air filter in the main hall is covered in dust, Front screen door is not in good repair, and main door will not close properly if screen door is closed. Blinds in room 1 are broken and in disrepair. Window sill in Room 1 have an accumulation of dead pests and spider webs. Rooms 2 and 6 door to the outside do not lock from the inside, and doors will automatically lock from the outside, which residents will not be able to re-enter their room from the outside. In addition, facility staff did not have keys for room door 2 and room door 6. The toilet in Room 3 is not maintained and clean. The bathroom toilet was not sanitary.

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SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN HERITAGE SENIOR CARE II	FACILITY NUMBER: 342701257
	VISIT DATE: 01/11/2024

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Bedroom 6 is not furnished and is not set up for resident use. Bedroom 3 dresser is blocking the the closet door making the closet inaccessible. Carbon detector located in the hallway was missing a battery and not in good repair. The Administrator inserted batteries, and carbon detector is working properly. The exterior patio tiles are raised and causing a tripping hazard. There are glass windows and furniture next to emergency exit gate.

Facility does not have sufficient staff to meet facility needs and care and supervision of residents in care. Facility has resident 1 that is in bed most of the day due to weakness in legs, and has a hoyer hoyer lift. Resident 1 requires stand by assistance at all times, and is a two person assist. Facility assessments also state resident 1 is not able to climb stairs require help with all activities of daily living. The facility has one non-ambulatory resident with a hoyer lift.

This pre-licensing is a result of a change of ownership (CHOW). Please see case management report dated 01/11/2024 for deficiencies found during pre-licensing visit.

The Administrator agrees to make all repairs by 01/19/2024 by 5:00 PM. The following items will be repaired

Clean resident bathrooms
Clean Window Sills
Repair front window screen door
Room 2 and 6 door locks need to be replaced (residents should be allowed to reenter their room from the outside and not be locked out).
Remove furniture and debris from exterior back yard (furniture and debris next to fire emergency gate)

The pre-licensing process will be completed after staffing issues have been addressed, fire clearance issues (to determine if residents are bedridden. Unknown at this time due to missing LIC 602 physician report) have been addressed, and Administrator hours issues have been addressed.

The applicant has not passed the pre-licensing component of the application process. LPAs will notify the Central Application Bureau (CAB) that the pre-licensing has not been completed. An exit interview was conducted, and a copy of this report has been provided to the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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