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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317215
Report Date: 06/17/2024
Date Signed: 06/19/2024 10:15:50 AM


Document Has Been Signed on 06/19/2024 10:15 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLDEN ACRES HOME AND CAREFACILITY NUMBER:
390317215
ADMINISTRATOR:MARICEL YAPOFACILITY TYPE:
740
ADDRESS:1101 CALIFORNIA STREETTELEPHONE:
(209) 838-3405
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:26CENSUS: 26DATE:
06/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marivic Teano-ChuaTIME COMPLETED:
03:30 PM
NARRATIVE
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Unannounced Plan of Correction visit made out to this facility on 06/17/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Marivic Teano-Chua. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 26 residents.
The purpose of this visit was to follow up on the deficiencies that were cited from a prior visit conducted on 05/09/2024 and to follow up on the Plan of Correction. The following deficiencies were observed and cited on 05/09/2024:
  • In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

  • Each resident's record shall contain at least the following information:


This facility did complete the Plan of Correction and provided all of the required forms and documents at this time.

Plan of Correction clearance letters were printed and copies were provided to the facility designated Administrator at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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