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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002859
Report Date: 01/25/2023
Date Signed: 01/25/2023 04:28:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/25/2023 04:28 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: 2DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Evelyn Balgos, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived to the facility at approximately 12:30 pm to conduct an unannounced annual/random visit to the facility on today's date. LPA Campbell was met by the administrator, Evelyn Balgos.

LPA explained that the purpose of the visit was to conduct an annual/random inspection. There are 2 residents residents that live in the home. The facility has a hospice waiver for 1.

LPA evaluated the physical plant to ensure the health and safety of the residents in care. LPA inspected the facility with Evelyn including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and the backyard. LPA observed the facility to be free of odor. Pathways are clear and there was no obstruction of the fire exits.. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. There are no bodies of water present in the facility at this time. LPA observed sufficient seven day non-perishable and two day perishable food supplies.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications and toxins are kept locked and inaccessible to clients. LPA reviewed 2 resident files, including admission agreements, health screenings and appraisals. LPA reviewed and compared resident medication vs. resident medication logs. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiency was observed today.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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