390317215-5-20-2021-27-AS-ABOE-C37RWW-20210520132349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390317215
Report Date: 05/20/2021
Date Signed: 05/20/2021 01:24:21 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 ACRES HOME AND CARE		FACILITY NUMBER:	390317215
ADMINISTRATOR:	MARICEL YAPO		FACILITY TYPE:	740
ADDRESS:	1101 CALIFORNIA STREET		TELEPHONE:	(209) 838-3405
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	26	CENSUS: 25	DATE:	05/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Marivic Teano Chua		TIME COMPLETED:	01:45 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	Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 5/20/21 at 11:30am. LPA met with Licensee Marivic Teano Chua and stated the purpose of today’s visit. LPA contacted Licensee prior to today's visit for COVID screening. LPA was allowed entry into the facility and was accompanied by Licensee throughout the inspection tour that is licensed to serve a total capacity of 26 clients today's census is 25. LPA observed four of four staff associated and cleared in Licensing Information System. LPA observed Administrator Certificate expires on 11/4/2022. LPA interacted with a random number of residents during this visit engaging in activities and dining maintaining social distancing and practicing COVID precautionary measures. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed resident rooms with required furniture and lighting, common dining and living areas, kitchen, and storage areas. The temperature inside the facility was measured at 69F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30F less than the outside temperature. The hot water was measured at 106F which is within regulatory range of 105F and 120*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA reviewed medications against MAR's, medications are packed by pharmacy administered as physician's orders. One resident refusal of medications documented on MAR. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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 4

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 ACRES HOME AND CARE	FACILITY NUMBER: 390317215
	VISIT DATE: 05/20/2021

NARRATIVE

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Continued from 809.
LPA observed window missing screen, broken patio table, loose bricks, shed without door, two cracked windows, and stored items not in working order on property grounds accessible to residents in care. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed call system not working and Administrator stated it was not in working order. Facility handles P & I monies, LPA observed the log is maintained correctly and there is no commingling of funds.

LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed emergency food supplies. The kitchen was observed clean and in good repair and refrigeration and freezer was within regulatory temperature range. LPA observed chemicals and kitchen knives locked and inaccessible to residents.

Upon a file review the following items were discussed to be submitted with any changes annually to LPA by 6/4/2021:

Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Affidavit Regarding Client/Resident Cash Resources LIC400
Emergency Disaster Plan LIC610E
Health Screening Report- Facility Personnel LIC503
In-service Training Program
First aid/CPR certificates

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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 ACRES HOME AND CARE	FACILITY NUMBER: 390317215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(i)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that there is not a signal system in working order. Licensee stated the facility does not have a call system in working order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2021
	Plan of Correction
1 2 3 4	The licensee agrees to submit a to LPA by POC due date and provide proof of work completed once upgraded system is installed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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 ACRES HOME AND CARE	FACILITY NUMBER: 390317215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the facility shall be in good repair at all times. LPA observed window missing screen, broken patio table loose bricks, shed without door, two cracked windows, and stored items not in working order on property grounds accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/17/2021
	Plan of Correction
1 2 3 4	The LIcensee agrees to submit pictures of work repairs to windows, screens, shed, and remove stored items not in working order to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4