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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002859
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:21:25 PM


Document Has Been Signed on 01/24/2024 03:21 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 1DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Evelyn V. Balgos, AdministratorTIME COMPLETED:
03:45 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) Victoria Brown arrived unannounced on 1/24/24 at 12:30PM to conduct a Required - 1 Year visit. LPA met with Evelyn Balgos, Administrator and explained the purpose of the visit. Licensing Fees are current. Administrator Certificate expires on 12/13/2024.

The facility is licensed for a capacity of 6 Non-ambulatory residents of which 4 may receive hospice care services. There is 1 resident receiving hospice care services at this time.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility.

LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The temperature inside the facility was observed to be at 68*F which is within the required range of 68-85*F. The hot water temperature was measured at 119.9 *F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 no deficiencies cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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 1