<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312403
Report Date: 06/11/2021
Date Signed: 06/11/2021 03:30:03 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 HAVENFACILITY NUMBER:
390312403
ADMINISTRATOR:ROWENA RAMIREZFACILITY TYPE:
740
ADDRESS:2324 LEVER BLVD.TELEPHONE:
(209) 464-4743
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:150CENSUS: DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Rowena Ramirez, AdministratorTIME COMPLETED:
03:29 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 6/11/21 at 12:48PM, LPA Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by support staff and screened upon entry for COVID precautions. LPA explained the purpose of the visit to support staff. Administrator Rowena Ramirez arrived at 1:42 PM and met with LPA. LPA explained the purpose of the visit to Administrator. Administrator accompanied LPA on facility tour.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 150 bed facility with a current census of 40. There is a entry lobby with a reception area. In addition, facility has separate areas for activities and dining with COVID precautions in place including social distancing noted.There is a separate activities area with a door that leads out to a garden area which is secured with alarms and perimeter fencing. Chemicals and medications were noted to not be accessible to residents in care. Activities calendars and menus were posted. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations throughout, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 119*F in 4 of the resident bathrooms and room temperature reads 76*F throughout. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. (Cont. on 809C)
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN HAVEN
FACILITY NUMBER: 390312403
VISIT DATE: 06/11/2021
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
26
27
28
29
30
31
32
The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 4/29/21. Facility has an emergency food and water supply in a seperate storage area in kitchen. LPA requested the following documents to be updated: LIC 500, LIC 610E, LIC 308.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Rowena Ramirez
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2