342701257-1-25-2024-27-AS-AMAZ-CZTUEV-20240125143147

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701257
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:31:52 PM

Document Has Been Signed on 01/25/2024 02:31 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:	01/25/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Yelena Bigelow and Pennina Tuimaualuga		TIME COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analysts (LPA) Avelina Martinez and Jaime Ivy-Canady arrived at this facility unannounced on 01/25/2023 at 9:00 AM to conduct a case management visit. LPAs met with Yelena Bigelow and Pennina Tuimaualuga and explained the purpose of the visit.

The purpose of the visit today, is in response to follow up on plan of corrections for deficiencies cited on January 11, 2024. LPAs toured the facility with Pennina Timaualuga on 01/25/2024. During the tour, LPAs observed the patio tiles continue to be raised off the ground creating a tripping hazard. In addition, room 3 dresser is blocking the closet door, which is making the closet inaccessible. Moreover the front door locks from the outside, and residents are not able to re-enter into the facility without having staff let them back into the facility.

LPAs conducted a resident file review, and LPAs obtained copies of resident documents. Pennina Tuimaualuga reported the landlord will be working on repairing the patio tiles. LPAs were informed a contractor would inspect the patio no later than February 02, 2023. LPA Jaimie Ivy-Canady will conduct a plan of correction visit to follow up on deficiency. Pennina Tuimaualuga agrees to email LPA Jaimie Ivy-Canady plan in regards to front door, room 2 and room 6 exit door locks by 01/26/2024 5:00 PM.

No deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided at the end of visit.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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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