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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002859
Report Date: 01/28/2025
Date Signed: 01/28/2025 10:34:09 AM

Document Has Been Signed on 01/28/2025 10:34 AM - 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/
DIRECTOR:		AURORA S MAIGUEFACILITY TYPE:
740
ADDRESS:8661 GRIMSBY COURTTELEPHONE:
(916) 714-3163
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/28/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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An Office Meeting was conducted today in the Sacramento Regional Office via Microsoft Teams. The announced meeting was conducted via Microsoft Teams on 1/28/2025 at 9:00am. The purpose of this office meeting is to discuss the Licensee's intent for the continuation of the licensed facility. Present in the meeting is Licensing Program Manager Stephen Richardson, Licensing Program Analyst Victoria Brown, Licensee Evelyn Balgos, Administrator(s) Aurora Maigue and Grant Depositar. There are 6 residents currently in the home.

Issues discussed during the meeting to remain in compliance were:
· CCL to notified in all steps of the process
· Letter of intent
· Change of Ownership plans and timeline for submission
· Responsibility of intended Licensee (Not Transferable)
· A completed resident roster to include responsible party contact information, relocation information of each resident for intended relocations and actual relocations
· 60 day notices to be provided to residents with a copy to Community Care Licensing (CCL)
· Physical License to be provided to CCL
· Participation in the closure survey is voluntary, but very much appreciated. https://www.surveymonkey.com/r/facilityclosure
· Closure visit to be conducted

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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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