390317215-5-4-2022-27-AS-MJEN-CE4S63-20220504133515

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390317215
Report Date: 05/04/2022
Date Signed: 05/04/2022 01:35:29 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/04/2022 01:35 PM - 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 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:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Maravic Teano-Chua		TIME COMPLETED:	01:40 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 5/4/22 Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a required annual visit. The facility is a single story building with one central entry point that used to be a hospital but has now been converted to a care home. LPA Jensen met with Licensee Maravic Teano-Chua and Marisel Teske and explained the purpose of today's visit. Administrator certificates were observed to be posted on the walls and current. LPA Jensen was temperature screened at the front desk in the main reception area. LPA Jensen toured the facility including but not limited to 5 client rooms, 5 in room resident bathrooms, 2 shower rooms, dining room, living room, laundry room, storage areas and grounds. During the course of the visit LPA Jensen interacted with multiple residents in their rooms and also within the common areas. The thermostat was set at 73 degrees which falls within the required range of 68-85 degrees. The water temperature was measured at 114.6 degrees which falls within the required range of 105 degrees to 120 degrees. The lighting and furniture were observed to be adequate throughout the facility. All window screens were found to be in good repair. The carbon monoxide alarms were tested and found to be in good repair. The call button system was tested and found to be in good working order. The fire extinguishers were last serviced on May 2, 2022 and are in compliance. A fire drill log was observed with fire drills being conducted at least quarterly. Fire safety inspection records were reviewed and the fire alarm system was determined to be in good working order as of 5/11/2021. The fire department is now currently conducting the safety inspection for 2022. Clark pest control service was at the facility conducting a regularly scheduled preventative maintenance service. Continued on 809-C......

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN ACRES HOME AND CARE	FACILITY NUMBER: 390317215
	VISIT DATE: 05/04/2022

NARRATIVE

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Continued from 809
LPA Jensen observed the kitchen and dining room to be sanitary. A menu was observed to be posted that accurately reflected what was being served. LPA Jensen observed the facility to have in excess of a two day supply of perishable food and 7 day supply of non-perishable food. The refrigerator temperature was measured at 10 degrees and the freezer was measured at -5 degrees for food storage safety. A 30 day supply of PPE was observed. LPA Jensen observed toxins and knives to be secured and inaccessible to clients. An adequate linen supply was observed.

All staff were verified as fingerprint cleared and associated to the facility. LPA Jensen reviewed 2 staff files which were determined to be in compliance. All staff participated in 1st aid training and the 1st aid training and CPR certificates are valid through April of 2023. All staff are vaccinated. 1 staff file was reviewed and determined to be complete.

The grounds were observed to be well landscaped, the outdoor smoking area was observed to clean and well maintained. LPA Jensen observed debris to be stored on the grounds including but not limited to battered shopping carts and a broken toilet.

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. An exit interview was conducted and a copy of this report along with appeal rights were given to the Administrator.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/04/2022 01:35 PM - It Cannot Be Edited

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: 05/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/18/2022 Section Cited	1 2 3 4 5 6 7	Personal Accomodations (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. The licensee did not meet this requirement as evidenced by:
	8 9 10 11 12 13 14	Based on LPA Jensen's observation of debris stored on grounds including broken toilet and damaged shopping carts as well as observation of unsanitary vents in shower. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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