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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 344700040
Report Date: 01/05/2024
Date Signed: 01/10/2024 11:54:01 AM

Document Has Been Signed on 01/10/2024 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:GOLDEN YEARS HOME CARE SOLUTIONS, INC.FACILITY NUMBER:
344700040
ADMINISTRATOR:BALLARD, CARRIEFACILITY TYPE:
300
ADDRESS:8920 EMERALD PARK DR., STE D1TELEPHONE:
(916) 333-0383
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: CENSUS: DATE:
01/05/2024
Annual/RandomUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carrie BallardTIME COMPLETED:
01:00 PM
NARRATIVE
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Home Care Services Branch (HCSB) Associate Government Program Analyst (AGPA) Megan Vigil, arrived at the business office of Golden Years In-Home Senior Care for a Two Year Required Inspection on 1.5.2023 at approximately 9:50 AM.

Upon arrival, AGPA Vigil identified herself and was greeted by Licensee, Carrie Ballard. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review, AGPA Vigil discussed the findings of the inspection with the Licensee. AGPA Vigil advised a deficiency was found and is noted on the 809D with a plan of corrections.

LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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Document Has Been Signed on 01/10/2024 11:54 AM - It Cannot Be Edited


Created By: Megan Vigil On 01/05/2024 at 12:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814

FACILITY NAME: GOLDEN YEARS HOME CARE SOLUTIONS, INC.
FACILITY NUMBER: 344700040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2024
Section Cited
1796.45 (a)
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...(a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease...
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Home Care Aides (HCA) do not have a TB clearance prior to caring for client. This poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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