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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002876
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:51:03 PM

Document Has Been Signed on 01/15/2025 12:51 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: 3DATE:
01/15/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Mark Graham, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) arrived at the facility and met with Administrator, Mark Graham, to follow-up regarding observations made during an inspection conducted on 1/03/2025.

LPA observed that staff member (S1) did not obtain a criminal background clearance prior to working at the facility on 1/03/2025.

Due to LPA's observations and records reviewed, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. A civil penalty in the amount of $100 is being assessed today due a one (1) staff member not receiving a criminal background clearance. Deficiency is listed on 809-D.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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Document Has Been Signed on 01/15/2025 12:51 PM - It Cannot Be Edited


Created By: Michael Hood On 01/15/2025 at 12:34 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: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2025
Section Cited
CCR
87355(j)

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87355 Criminal Record Clearance (j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding criminal background clearances and ensure that new staff obtain a criminal background clearance before working with residents. Facility will submit statement to LPA by POC due date.
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Based on records reviewed, facility did not ensure that a criminal record clearance was obtained for one (1) staff member, which poses an immediate health, safety or personal rights risk to persons in care.
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A civil penalty in the amount of $100 was assessed for today's date regarding staff not having a criminal background clearance.

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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.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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