<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002859
Report Date: 01/24/2022
Date Signed: 01/24/2022 01:09:17 PM

Document Has Been Signed on 01/24/2022 01:09 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN VALLEY SENIORS GRIMSBYFACILITY NUMBER:
347002859
ADMINISTRATOR:BALGOS, EVELYNFACILITY TYPE:
740
ADDRESS:8661 GRIMSBY COURTTELEPHONE:
(916) 714-3163
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
01/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Evelyn Balgos - AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Annual required infection control inspection. LPA met with Administrator Evelyn Balgos in the facility. LPA explained the purpose of the visit then was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility. Administrator Certificate #6023016740 Expires 12/13/2022 .

LPA conducted a tour of the facility with the Administrator. The physical plant is consistent with the submitted facility sketch/floor plan and has the COVID-19 health and safety signs. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility's kitchen is free of debris. Food and water supply were observed as sufficient. The hot water measured 110.3*F which is within the required range of 105-120*F. LPA observed the facility's restrooms as clean and equipped with hand washing signs. The facility's backyard was free of debris.

The residents' bedrooms were inspected and all had the required lighting and furniture. Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguishers expire 2/5/2022. The facility's first aid kit included the required tweezers, scissors, and a thermometer. Cleaning solutions were locked up.

LPA reviewed facility procedures for visitation entrance, temperature checks and logs, COVID-19 isolation, PPE, food and cleaning supply storage.

Licensee is retiring in December of 2022 and will not own the facility anymore.

Per California Code of Regulations, Title 22, no deficiencies were cited.
Exit interview. Copy of report provided to administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2022
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 1