390317215-5-4-2023-27-AS-JFAN-CRHUUU-20230504155407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390317215
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:54:39 PM

Document Has Been Signed on 05/04/2023 03:54 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
SACRAMENTO AC/SC, 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: 26	DATE:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:			TIME COMPLETED:	04:00 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 May 4, 2023 at approximately 9:30am, LPA Jennifer Fain and LPA Maja Jensen arrived at the facility unannounced. LPA's Fain and Jensen met with Maravic Teano-Chua and explained the purpose of today's visit. Licensing Program Analysts (LPA's) Maja Jensen and Jennifer Fain conducted a Required 1 year annual inspection. LPA's met with Administrator, Maricel Yapo and Licensee Maravic Teano- Chua. LPA's, Licensee and administrator toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA's observed lighting in all rooms is adequate for the comfort and safety of the residents. There is a minimum of a seven day supply of nonperishable and two day supply of perishable foods. Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguishers were last serviced on 5/4/2023. First aid kit was observed to be complete. Fire drill was last conducted on 4/22/2023. LPA's observed hot water temperature in resident room sink measured at 105.5 degrees F. Current copies of the following documents were observed on wall near desk: LIC 308 Designation of Administrative Responsibility, Administrator Certificate, and Facility Sketch. Continued on 809C...

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN ACRES HOME AND CARE	FACILITY NUMBER: 390317215
	VISIT DATE: 05/04/2023

NARRATIVE

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LPA's Jensen and Fain observed significant ceiling damage in three bedrooms including two areas of ceiling covered by tarp and held in place by wood strips. The area cover by a tarp was approximately 4 feet by 5 feet. LPA's Fain and Jensen interviewed Administrator Maricel Yapo- Teske who advised the ceiling damage was a result of a leak in the roof. Administrator Yapo- Teske provided contract for roof repair .

LPA's Jensen and Fain observed water pooling in sink in resident room during water temperature check. LPA Jensen reviewed 5 of 26 resident files. One of five resident files contained notes regarding a resident that was sent to the hospital in April of 2023 with an urgent medical condition, however, no incident report was received by the Department. LPA Jensen reviewed 2 of 4 staff files. Which were determined to be complete and in compliance.

The grounds were observed to be maintained, clear of debris and all pathways were clear of obstruction. There is outdoor furniture and a shaded area for outdoor activities.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22.
Failure to correct deficiencies may result in the assessment of Civil Penalties.

An exit interview was conducted and a copy of this report and Appeal Rights were provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/04/2023 03:54 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
SACRAMENTO AC/SC, 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: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

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 LPAs observation of ceiling damage in teh bedrooms and water pooling in the resident bedroom sink, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to have the roof, ceiling and plumbing repaired and to email repair invoices to maja.jensen@dss.ca.gov by Plan of Correction due date.

Type B

Section Cited

CCR

87211(a)(1)(D)

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs review of a resident file and an interview with Administrator Maricel Tapo-Teske, the licensee did not comply with the section cited which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to conduct in service training on reporting requirements and email proof of completion to maja.jensen@dss.ca.gov by Plan of Correction due date.

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: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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