347004863-4-28-2023-59-AS-DAWL-CRBPT4-20230428113520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004863
Report Date: 04/28/2023
Date Signed: 04/28/2023 11:35:43 AM

Document Has Been Signed on 04/28/2023 11:35 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME:	GOLDEN VILLA RCFE AT NATOMAS PARK		FACILITY NUMBER:	347004863
ADMINISTRATOR:	FLORES, JULIETA A.		FACILITY TYPE:	740
ADDRESS:	5618 JOHN RUNGE ST.		TELEPHONE:	(916) 239-9372
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	6	CENSUS: 2	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	Julieta Flores, Administrator		TIME COMPLETED:	12:00 PM

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On April 28, 2023, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required 1 year inspection. LPA met with Julieta Flores, Administrator and informed her the reason for the visit. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19, and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore a mask for PPE.

Julieta and LPA could not complete the inspection tool. LPA was having computer problems. (see 812)

The Administrator certificate expires 10/26/2024. The current census is 2. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 76 degrees F which is within range.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 114 degrees F, which is within the allowed range of 105-120 degrees. There’s appropriate lighting throughout the facility.

To continue see 809-C...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN VILLA RCFE AT NATOMAS PARK	FACILITY NUMBER: 347004863
	VISIT DATE: 04/28/2023

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The facility is a one-story home. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured.

All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. Hot water temperature is 114 degrees F. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible.

There’s a centralized storage area for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log and was complete and current.

First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. The facility was observed to have been annually inspected on March 28, 2023, by Fire Code and is in compliance at this time. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

LPA reviewed 2 resident files and 2 staff files. Resident's Records reviewed indicated Emergency Contacts, Assessments, Admission Agreements and Physician's Reports were all current and up to date. Staff records reviewed revealed current First Aid & CPR certificates, Health Screenings and Emergency Contacts were all up to date and the facility is conducting staff training as required

Per California Code of Regulations Title 22, no Deficiencies observed or cited during this visit.

An exit interview was conducted and a copy of this report was given to Julieta.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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