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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002876
Report Date: 03/14/2024
Date Signed: 03/14/2024 02:50:10 PM


Document Has Been Signed on 03/14/2024 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLDEN MOMENTS CARE HOME WINDING WAYFACILITY NUMBER:
345002876
ADMINISTRATOR:DAHLEY, DALEEFACILITY TYPE:
740
ADDRESS:4316 ILLINOIS AVENUETELEPHONE:
(916) 474-4678
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Stephanie Harmon-Christensen, CaregiverTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 3/14/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and three (3) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 115.6 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Section 87203 regarding fire extinguishers not being serviced, Section 87309(a) regarding chemicals being accessible to residents, and Section 87615(a) regarding acceptance and retention of a resident with a prohibited health condition without an exception from CCLD. Deficiencies are listed on 809-D.

Exit interview was conducted with caregiver. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/14/2024 02:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 WAY
FACILITY NUMBER: 345002876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the facility did not ensure that chemicals and disinfectants were locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Facility will ensure that all cleaning products are locked and inaccessible to the residents in care. Facility will complete a statement of understanding regarding regulation 87309 and submit statement to LPA by POC due date of 3/15/2024.
Type A
Section Cited
CCR
87615(a)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, LPA's observation, and records reviewed, the facility did not ensure to obtain an exception for a prohibited health condition before accepting and retaining a resident using a G-tube, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Facility will ensure that they receive an exception before admitting residents with prohibited health conditions. Facility will submit an exception request for one (1) resident with G-Tube to LPA by POC due date of 3/15/2024.
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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/14/2024 02:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 WAY
FACILITY NUMBER: 345002876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the facility did not ensure that fire extinguisher was serviced, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Facility will service fire extinguisher and provide LPA proof of service by POC due date of 3/15/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3