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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312403
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:55:35 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/31/2023 11:55 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
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: 39DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Gemma SisonTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Gemma Sison. Later joined by Dr. Ramirez Administrator.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 120 degrees Fahrenheit in client's bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs.

LPA reviewed 15 resident and 5 staff files, including criminal record clearances.
First aid kit was checked and is complete. LPA observed a carbon monoxide detectors in the facility. Fire drill was conducted on 11/28/2022.

No deficiencies cited pursuant to Title 22 rules and regulations, Health and Safety Codes.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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