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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004362
Report Date: 01/27/2021
Date Signed: 01/27/2021 02:02:38 PM

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 MOMENTS CARE HOME, INC.FACILITY NUMBER:
347004362
ADMINISTRATOR:MAKAYLA WHITEFACILITY TYPE:
740
ADDRESS:2651 ARMSTRONG DR.TELEPHONE:
(916) 979-9828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 5DATE:
01/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Makayla White, AdministratorTIME COMPLETED:
01:20 PM
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On 01/27/2021 at 1:07 PM Licensing Program Analyst (LPA) McCrory conducted a tele-visit with Administrator (Admin) Makayla White via FaceTime due to COVID-19 precautionary reasons.
The tele-visit was conducted as an unannounced Case Management Health and Safety Check due to a power outage caused by weather conditions.

Below is pertinent information regarding the visit:
  • Physical plant appears clean and free of debris.
  • LPA viewed five (5) residents eating in various locations of the living/dining room.
  • LPA viewed one resident receiving staff assistance at a table with eating food.
  • All residents appeared alert and responded to LPA waving during the Facetime visit.
  • All residents appeared to have multiple layers of clothing such as jackets, blankets, and hats.
  • Admin states staffing is adequate.
  • Admin states Personal Protective Equipment (PPE) is adequate.
  • LPA viewed non-perishables stored in cabinets which meet the minimum requirement of one week.
  • LPA viewed three (3) generators currently providing emergency power to the facility.
  • LPA viewed space heaters in the common area where residents were currently located.
  • LPA viewed ten (10) flashlights: some could light an entire room or be used as a lantern.
  • Facility has three (3) bedrooms.
  • Admin states if power is not on this evening the generators will be redirected to the back of the house where the bedrooms are. Power will be used for space heaters to warm residents in their rooms.
  • Admin states she will be at the facility on shift until this issue is resolved.
  • Admin states there are no services that Community Care Licensing (CCL) can provide at the moment.

An exit interview was conducted. A copy of this report has been emailed to the facility. The Administrator was advised that a signed copy of the report shall be submitted to CCL within 10 days of receipt of this report.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021
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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