347003562-7-3-2026-27-AS-RJAY-DVMVHC-20260703162655

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003562
Report Date: 07/03/2026
Date Signed: 07/03/2026 04:29:58 PM

Document Has Been Signed on 07/03/2026 04:29 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 YEARS CARE HOME I		FACILITY NUMBER:	347003562
ADMINISTRATOR/ DIRECTOR:	BERNARDINO, GRACE C.		FACILITY TYPE:	740
ADDRESS:	8516 FOXBERRY COURT		TELEPHONE:	(916) 681-3726
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY: 6		CENSUS: 6	DATE:	07/03/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Grace Bernardino		TIME VISIT/ INSPECTION COMPLETED:	04:30 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	On 7/3/2026 at 9:50 am, Licensing Program Analysts (LPAs) Reza Jamaly and Christina Valerio arrived unannounced at the facility to conduct 1- year required inspection.LPAs initially met with staff one duty and explained the purpose of the visit. The administrator, Grace Bernardino was notified of the visit and arrived shortly after. Pascua Grace assisted with today’s visit. Administrator certificate #7002401740 is and will expire on 09/12/2027 . The current census is 6 with 2 facility staff. Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to six elderly residents, up to six may be non-ambulatory. Facility has a hospice waiver for 3 residents. Areas inspected include, but not limited to, the kitchen, dining area, resident units, resident bathrooms, laundry room, dining room and outdoor areas to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) non-ambulatory residents. LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed 6 bedrooms to be properly furnished with appropriate bedding and lighting. Adequate linen supply was observed. Grab bars and non-slip mat were observed to be stable and in good repair at this time. There are no bodies of water present. In the kitchen/dining area, LPAs observed at least 7-day nonperishable and 2-day perishable food items. LPA inspected medication storage a the corner of the kitchen, at least one medication drawer observed to be unlocked and an antiseptic (Isopropyl Alcohol) was observed inside it. Continues on LIC 9099C page 2

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN YEARS CARE HOME I	FACILITY NUMBER: 347003562
	VISIT DATE: 07/03/2026

NARRATIVE

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LPA inspected 2 freezers and fridges no thermometers were observed a one of the fridges and freezer and one thermometer observed in another fridge and temperature reads 46.6 which is not in rage of 40-0 degree Fahrenheit. Technical Advisory provided to obtain thermometers for each refrigerator and freezer to ensure regulatory temperature is maintained at all times. Knives/sharps were locked in a drawer, but magnet lock observed to be loose. Administrator fixed it right away. Fire extinguishers observed and last serviced on 11/19/2025. Smoke detectors were observed and one of them was tested and was working.

Hot water temperature was measured at the bathroom, it was measured 115.1 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. The last fire drill was conducted on April 2026. LPAs observed the facility has a has a public telephone in the Kitchen and the facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit.

LPA inspected outdoor areas, a pickaxe was observed during the physical inspection. LPAs observed a storage in the yard unlocked and a chainsaw was observed inside of it. Type A deficiency was cited for this observation.

LPA reviewed 3 out of 6 resident medications and medication administration record (MAR) and it was complete. The first aid kit was checked and contained the required components.

LPAs requested resident and staff files for review. LPAs reviewed 3 out of 6 resident files and they were complete. LPA reviewed 2 staff files, and it was complete.

LPAs reviewed staff criminal record clearances, and 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.

Continues on LIC 9099C on page 3..

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN YEARS CARE HOME I	FACILITY NUMBER: 347003562
	VISIT DATE: 07/03/2026

NARRATIVE

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The following documents will be email to LPA by 07/07/2026 end of day 5:00 PM:

(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D pages. An exit interview was conducted with and a copy of these LIC 809 reports, LIC 809-D pages, and Appeals rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/03/2026 04:29 PM - It Cannot Be Edited

Created By: Reza Jamaly On 07/03/2026 at 01:27 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GOLDEN YEARS CARE HOME I	FACILITY NUMBER: 347003562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(c)

Storage Space and Access

(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation a pickaxe observed at the yard and a chainsaw was observed inside an unlocked storage, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/04/2026
	Plan of Correction
1 2 3 4	Administrator secured the pickaxe, put it in the storage and locked it. POC was completed during today's inspection.

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.

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/03/2026 04:29 PM - It Cannot Be Edited

Created By: Reza Jamaly On 07/03/2026 at 01:27 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GOLDEN YEARS CARE HOME I	FACILITY NUMBER: 347003562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(21)

General Food Service Requirements

(21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, freezer temperature was 46.6 Degree F which is not incompliance with Title 22 Regulation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2026
	Plan of Correction
1 2 3 4	Administrator will provide training for the staff to maintain the refrigerator temperature with the maximum temperature of 40 degree F. (4 degree C). Licensee will send a picture of refrigerator thermometer showing the degree below 40 degree F. (4 degree C).

Type B

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because a bottle of antiseptic was observed inside unlocked medication drawer which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2026
	Plan of Correction
1 2 3 4	Administrator will provide training for staff on 87465 and send a copy of training completion document showing title of training, staff name and signature.

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

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026

LIC809 (FAS) - (06/04)

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