347003563-7-21-2026-27-AS-RJAY-DW7VQM-20260721163835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003563
Report Date: 07/21/2026
Date Signed: 07/21/2026 04:38:50 PM

Document Has Been Signed on 07/21/2026 04:38 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 II		FACILITY NUMBER:	347003563
ADMINISTRATOR/ DIRECTOR:	BERNARDINO, GRACE C.		FACILITY TYPE:	740
ADDRESS:	8786 SILVERBERRY AVENUE		TELEPHONE:	(916) 681-3726
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY: 6		CENSUS: 6	DATE:	07/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Administrator Grace Bernardino		TIME VISIT/ INSPECTION COMPLETED:	04:45 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	On 7/21/2026, at 2:15 PM Licensing Program Analysts (LPAs) Reza Jamaly arrived unannounced at the facility to conduct the required annual inspection. LPAs met with staff on duty who assisted LPA touring the facility then administrator Grace Bernardino joined the meeting. Administrator certificate expires on 9/12/2027. Facility is cleared for 6 residents and census was 6. Firstly, LPA Jamaly inspected the physical plant including but not limited to the common area, kitchen, dining area, 6 resident's bedrooms, resident bathrooms, and outside courtyard of the facility to ensure compliance with Title 22 regulations. LPAs inspected the kitchen and observed a sufficient supply of at least a seven-day supply of nonperishable food and a two-day supply of perishable food. Sharp knives were secured in a locked kitchen cabinet and inaccessible to resident. LPA checked two refrigerator and freezer, one located in kitchen and another outside in front of living room. LPA inspected 6 resident's bedrooms and observed bedrooms to be properly furnished with appropriate bedding and lighting. Resident's bathrooms observed to be cleaned, grab bars and non-slip mats were observed to be secure and in good condition. The hot water temperature measured 108.8 at one of the resident bathroom sink, which is within the required range of 105°F to 120°F. Facility temperature was checked at living room and observed to be 76 degree F. There are no bodies of water present. Continue in LIC 809C in page 2

Stephen Richardson
Reza Jamaly
	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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 II	FACILITY NUMBER: 347003563
	VISIT DATE: 07/21/2026

NARRATIVE

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Smoke detectors and carbon monoxide detectors were observed at hallways and living rooms. Two fire extinguishers, located in living room and in kitchen, was last serviced on 11/04/2026. Last fire drill conducted on 6/16/2026.
LPA observed that the facility maintained a public telephone in the kitchen and that all required licensing posters were properly displayed
Cleaning supplies and other toxic substances were observed in a cabinet in the laundry room, inaccessible to resident and administrator unlocked garage's door for LPA inspection.
Medication were observed to be stored in a locked cabinet in the kitchen and inaccessible to residents. LPA reviewed 3 of 6 residents' centrally stored medication record and MAR which were complete and consistent with physician's orders. The first aid kit was inspected and contained all required supplies.
LPA requested resident and staff records for review. LPA reviewed 3 out 6 resident's file and found them to be complete. Two (2) staff files were reviewed and found to be complete. A review of personnel records confirmed that all staff members and other individuals required to undergo caregiver background checks had received criminal record clearances and were properly associated with the facility.
The following documents were requested and will be emailed to the LPA by 7/16/2026 no later than 5:00 PM.

LIC 308 – Designation of Administrative Responsibility
Copy of the Administrator Certificate
LIC 610 – Emergency Disaster Plan
Proof of Current Liability Insurance
LIC 500 – Personnel Report
LIC 309 – Administrative Organization

Based on today's inspection, the facility was found to be in compliance with applicable Title 22 regulations. An exit interview was conducted with Grace Bernardino , and a copy of the LIC 809 Report was provided to the facility representative.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC809 (FAS) - (06/04)

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