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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002876
Report Date: 11/25/2025
Date Signed: 11/25/2025 04:47:55 PM

Document Has Been Signed on 11/25/2025 04:47 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN MOMENTS CARE HOME WINDING WAYFACILITY NUMBER:
345002876
ADMINISTRATOR/
DIRECTOR:		DAHLEY, DALEEFACILITY TYPE:
740
ADDRESS:4316 ILLINOIS AVENUETELEPHONE:
(916) 474-4678
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 5DATE:
11/25/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Stephanie Harmon-Christensen, House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michael Hood and Marisa Chiarelli arrived at the facility and met with House Manager, Stephanie Harmon-Christensen, to address and discuss concerns regarding the most recent inspections conducted on November 24, 2025 and November 25, 2025.

During visit conducted on November 24, 2025, LPA Hood observed staff member (S1) working at the facility by themselves. LPA observed that S1 did not have a criminal background clearance on file. S1 also did not have a First Aid/CPR card on file.

During visit conducted on November 25, 2025, LPAs observed staff member (S2) working at the facility without a criminal background clearance. S2 also did not have a First Aid card on file. Facility was unable to provide any staff records during visit.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Civil penalties in the amount of $100 each are being assessed today due a two (2) staff not receiving a criminal background clearance. Deficiencies are listed on 809-D.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/25/2025 04:47 PM - It Cannot Be Edited


Created By: Michael Hood On 11/25/2025 at 04:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN MOMENTS CARE HOME WINDING WAY
FACILITY NUMBER: 345002876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2025
Section Cited
CCR
87355(d)(3)

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87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted... (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
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Facility will create a plan regarding staffing, including the process of hiring new staff. Facility will submit plan to LPA by POC due date.
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Based on LPA's observations, facility did not ensure that a criminal record clearance was obtained for two (2) staff members, which poses an immediate health, safety or personal rights risk to persons in care.
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Civil penalties in the amount of $100 each were assessed for today's date regarding staff not having a criminal background clearance.
Type A
11/26/2025
Section Cited
CCR87411(c)(1)

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87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
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Facility will ensure that staff missing first aid training obtain first aid training. Facility will submit proof of completed training to LPA by POC due date.
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Based on LPA's observations, facility did not ensure that two (2) staff members had first aid training on file, which poses an immediate health, safety or personal rights risk to persons 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Michael Hood
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/25/2025 04:47 PM - It Cannot Be Edited


Created By: Michael Hood On 11/25/2025 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN MOMENTS CARE HOME WINDING WAY
FACILITY NUMBER: 345002876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2025
Section Cited
CCR
87412(f)

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87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement is not met as evidenced by:
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Facility will establish personnel records for licensing agency to inspect. LPA will return to facility at a later time to clear POC.
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Based on LPA's observations, facility did not ensure to make personnel records available to licensing agency to inspect, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
11/26/2025
Section Cited
HSC1569.618

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ยง1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
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Facility will ensure that there is at least one (1) staff member on the premises who is CPR certified. Facility will ensure that staff missing CPR training obtain CPR training. Facility will submit proof of completed training to LPA by POC due date.
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Based on LPA's observations, the facility did not ensure that one (1) staff member had CPR training on file, which poses an immediate health, safety or personal rights risk to persons 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Michael Hood
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
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