347002889-11-27-2023-59-AS-SCAA-CXYUP9-20231127144509

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347002889
Report Date: 11/27/2023
Date Signed: 11/27/2023 02:45:26 PM

Document Has Been Signed on 11/27/2023 02:45 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	GOLDEN CREST CARE CENTER		FACILITY NUMBER:	347002889
ADMINISTRATOR:	VICTOR BURACHEK		FACILITY TYPE:	740
ADDRESS:	8120 PATTON AVENUE		TELEPHONE:	(916) 725-6766
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 5	DATE:	11/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Victor Burachek, Administrator		TIME COMPLETED:	02:45 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) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Administrator, Victor Burachek, and Natalia Burachek, caregiver and explained purpose of inspection. LPA observed (1) resident watching television in his wheelchair in the common area and (4) residents in their rooms. LPA observed a physical therapist staff arrive to care for one resident.The facility is licensed for (5) non-ambulatory and (1) ambulatory residents and has a hospice waiver for (1). Currently there are (5) residents and no residents are under hospice care. LPA and the Administrator toured the interior and exterior of the facility including the common areas, (6) resident bedrooms, (2) shower rooms, (4) resident bathrooms, kitchen, office, laundry area and garage. LPA observed the facility to be clean, in good repair and odor-free, and the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable supply of food, including fresh produce, and 7+day non-perishable supply of food. Sharps, toxins and medications were locked in the kitchen. LPA observed sufficient linens/blankets/incontinent supplies, PPE, and a complete First Aid kit. The inside temperature was 72F. Hot water temperature measured 110F in a resident bathroom. The fire extinguisher was last serviced 12/28/22 and will be serviced again by 12/28/23. Fire/smoke monoxide alarms are in working order. There is an unlocked exit in the backyard and plenty of outdoor/indoor space for activities. There are no pools. LPA reviewed (4) of (5) resident files- files were organized and contain current documents. Medications were reviewed for (3) residents and no discrepancies were noted. Documentation is maintained and meds are pre-poured only for the day. (2) of (2) staff files were reviewed. RCFE Administrator certificate is pending renewal per on-line check today. Documentation of training requested to be kept on file. CPR/First Aid is due in November 2023- to be completed and documentation provided. cont on 809C-1..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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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Document Has Been Signed on 11/27/2023 02:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN CREST CARE CENTER	FACILITY NUMBER: 347002889
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with the Administrator, and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator agree to obtain liability insurance meeting the requirements stated above and provide documentation to the Department by 12/11/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN CREST CARE CENTER	FACILITY NUMBER: 347002889
	VISIT DATE: 11/27/2023

NARRATIVE

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809C-1... Infection Control Plan was reviewed- LIC9282 provided as courtesy. LPA provided updated copy of LIC613-2- Personal Rights to be provided to residents and posted.

LPA obtained an updated copy of LIC308 and requested an updated copy of LIC500 and LIC610E (Emergency Disaster Plan) by 12/4/23.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 809D page.

Exit interview. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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