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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002876
Report Date: 03/28/2022
Date Signed: 03/28/2022 02:50:46 PM


Document Has Been Signed on 03/28/2022 02:50 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GOLDEN MOMENTS CARE HOME WINDING WAYFACILITY NUMBER:
345002876
ADMINISTRATOR:STROUP, JENNIFERFACILITY TYPE:
740
ADDRESS:4316 ILLINOIS AVENUETELEPHONE:
(916) 474-4678
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
03/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Michelle ReyesTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 3/28/22 to conduct a Pre-licensing follow-up inspection for facility change of ownership. LPA met with caregiver/ designated responsible staff and explained the reason for the visit. LPA also spoke with Mark Graham by phone. Prior to initiating the pre-licensing inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Administrator is not available at the time of this visit .

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator arrived at the facility. LPA, Administrator, and Infection control Leader completed the infection control recommendations and facility was found to be in substantial compliance at this time.
The home is clean, safe and sanitary. Food supplies meet requirements. Water temperature measured at 115 degrees F.

LPA advised facility of fire regulation that fire doors be unobstructed and free of door stops. Fire doors were cleared while LPA present. LPA also advised that additional symptoms be added to screening (example provided).
During this visit, this facility is in substantial compliance and meets the minimum requirements for a RCFE license. Component III was waived. Application is pending further review.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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