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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 344700040
Report Date: 09/25/2024
Date Signed: 09/26/2024 09:01:39 AM

Document Has Been Signed on 09/26/2024 09:01 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/
DIRECTOR:		BALLARD, CARRIEFACILITY TYPE:
300
ADDRESS:8920 EMERALD PARK DR., STE D1TELEPHONE:
(916) 333-0383
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: CENSUS: DATE:
09/25/2024
Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Danielle ToluwanimiTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Enforcement Analyst (EA), Megan Vigil arrived at the business office of Golden Years Home Care Solutions, INC. for a complaint investigation.

EA, Vigil was greeted by Designee, Danielle Toluwanimi. EA, Vigil requested payroll, schedule, and training transcripts for the last quarter for all employees. The file review was completed and EA, Vigil, discovered there were deficiencies found and are noted on the 809D with a plan of corrections and appeal rights.

LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/26/2024 09:01 AM - It Cannot Be Edited


Created By: Megan Vigil On 09/25/2024 at 01:52 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: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2024
Section Cited
1796.43
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(a) Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients.
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Two employees did not have an eligible or cleared status and the background check for the Home Care Aide (HCA) registry . 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: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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