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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701257
Report Date: 05/20/2024
Date Signed: 05/20/2024 11:53:05 AM


Document Has Been Signed on 05/20/2024 11:53 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
05/20/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Yelena BigelowTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a postlicensing inspection. LPA Moleski met with facility administrator Yelena Bigelow and explained the purpose of the visit.

When LPA Moleski arrived, he was met by a staff member (S1). LPA Moleski reviewed Guardian records and observed that S1 was not associated to this facility. S1 told LPA Moleski S1 had been working at this facility for about two to three months. Bigelow submitted a transfer request and S1 was associated during this visit.

S1 showed LPA Moleski a closet containing cleaning solutions and other cleaning supplies. S1 said the lock to the closet had been broken since approximately 11 p.m. the previous night. Bigelow removed the cleaners during this visit.

LPA Moleski reviewed five resident files (R1-R5) and one staff file (S1).

LPA Moleski toured the facility with Bigelow and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. While inspecting the kitchen, LPA Moleski observed several medications being stored in an unlocked cabinet.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed a locked box for the storage of knives. LPA Moleski interviewed one staff member (S1) and two residents (R2-R3).

This facility is hereby cited per 22 CCR Sections 87309(a), 87465(h)(2), and 87355(e)(3). A civil penalty in the amount of $100 per day worked by S1 for a maximum of five days is hereby assessed. An exit interview was held with Bigelow. Appeal rights and a copy of this report were left with Bigelow.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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 3


Document Has Been Signed on 05/20/2024 11:53 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cleaning solutions were left unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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The cleaning solutions were locked up during this visit. This POC will be cleared.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, S1 was not associated to this facility prior to starting work, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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Licensee associated this staff member during this visit. This POC will be cleared.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/20/2024 11:53 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, medications were left unlocked and accessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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Licensee locked up the medications during this visit. This POC will be cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3