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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001254
Report Date: 02/25/2021
Date Signed: 02/25/2021 02:15:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDIN CARE 1FACILITY NUMBER:
347001254
ADMINISTRATOR:DANIELLE E HAZZIEZFACILITY TYPE:
740
ADDRESS:108 REMINGTON DRIVETELEPHONE:
(916) 983-1721
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: DATE:
02/25/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility after completing weekly COVID-19 test and daily self assessment. LPA took temperature prior to leaving and was 97.5 degrees. LPA was greeted by Diandre Scantelbury (Caregiver) when entering and was wearing N-95 mask along with gloves. LPA screened for COVID-19 symptoms and temperature was taken and read 98.7. LPA informed Diandre the purpose of this visit was a health and wellness check.

LPA toured the facility, viewing three (3) of three (3) rooms, speaking with one (1) of three (3) residents and one (1) of (4) staff. LPA noted there was one staff at facility. Staff stated Administrator left roughly twenty (20) minutes ago, and staff's shift is 8:30a.m.-5:00p.m. when he is relieved by another staff.

LPA Noted R1 was in bedroom two (2) and R2 and R3 shared bedroom one (1). Bedroom three (3) is currently unoccupied.

LPA spoke with R2 for a short time, and asked how long resident has been staying at facility, R2 stated the last couple of years. LPA asked if R2's needs were being met and was informed yes, R2 stated she is happy in this home.

While touring facility, LPA viewed postings regarding COVID-19. LPA reviewed the food supply at facility and noted a sufficient supply of both perishable and nonperishable goods.

LPA conducted exit interview with Diandre Scantelbury (Caregiver) and obtained signature. LPA is to provide signed report via email with read receipt to ensure delivery. No deficiencies were cited at this time.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021
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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