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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003562
Report Date: 04/24/2023
Date Signed: 04/24/2023 11:16:03 AM


Document Has Been Signed on 04/24/2023 11:16 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GOLDEN YEARS CARE HOME IFACILITY NUMBER:
347003562
ADMINISTRATOR:BERNARDINO, GRACE C.FACILITY TYPE:
740
ADDRESS:8516 FOXBERRY COURTTELEPHONE:
(916) 681-3726
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 4DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Grace Bernardino - AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA's) Ruth Wallace and Jennifer Fain conducted a Required 1 year annual inspection. LPA's met with Administrator and explained the purpose of today’s inspection.

LPA's and administrator toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA's observed lighting in all rooms are adequate for the comfort and safety of the residents. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on 11/1/2023. Emergency Disaster Plan last updated 01/02/2022. First aid kit was observed to be complete. Fire drill was last conducted on 3/23/2023. LPA's observed completed mitigation plan. LPA's observed hot water temperature in kitchen sink which measured at 106.5 degrees F.

Updated copies of the following documents were received on 4/24/2023:
LIC 308 Designation of Administrative Responsibility
Copy of Administrator

No deficiencies were observed or cited from the California Code of Regulations, Title 22.

Exit interview conducted with Administrator and a copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
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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