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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 390317215
Report Date: 05/23/2023
Date Signed: 05/23/2023 05:59:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230505082832
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:
05/23/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maricel TeskeTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not ensure the roof was fixed timely
Staff did not ensure the facility was kept mold free
INVESTIGATION FINDINGS:
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On 5/23/23 at approximately 2:00pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with care provider Maricel Teske and explained the purpose of today's visit. LPA Jensen also spoke to Licensee Marivic Teano-Chua by telephone and explained the purpose of today's visit.

During the course of the investigation LPA Jensen inspected all facility rooms, including storage areas and the basement. In addition, LPA Jensen interviewed 2 staff members, 5 clients and a laborer with a roofing company performing work at the facility. The Licensee and staff confirmed during the course of an interview that the roof started leaking in January of 2023. An environmental services company was retained to conduct a mold inspection and this inspection was completed on 5/9/2023. Based on a review of the mold inspection report, 4 air samples were taken. A laboratory analysis was conducted on the 4 air samples taken and 4 of 4 samples registered moderate to high mold spore levels.

Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20230505082832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2023
Section Cited
CCR
87303(a)
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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 was not met as evidenced by:
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The Licensee has begun mold abatement and remediation and agrees to schedule additional testing of other areas in the facility by 5/24/23. The Licensee also agrees to schedule by 5/24/23, mold abatement and remediation work for the 2 remaining areas where air samples were taken.
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Based on LPA Jensen's review of a Mold Inspection Report and visual inspection of the facility staff did not ensure the facility was kept free of mold. This poses a potential risk to the health, safety and personal rights of residents in care.
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Type B
06/02/2023
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements

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....
Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by:
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The Licensee agrees to conduct in-service training on reporting requirements and submit proof of completion via email to maja.jensen@dss.ca.gov by 5/26/23.
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Based on interviews conducted the roof leaks occurred in January of 2023 and were not reported to the Department. This poses a potential health, safety and personal rights risk to residents in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20230505082832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/23/2023
NARRATIVE
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The Licensee met with a Certified Mold Remediation Consultant (CMC). LPA Jensen reviewed the CMC report which states the remediation estimate is based on a visual inspection and analysis of air samples collected and paid for by the client and that due to the nature of microscopic mold spores and the possibility of their elevated presence inside the property additional testing may be warranted or contamination can be assumed in any or all non-work areas on the property.

Mold Abatement remediation has been performed in two of the 4 areas identified with moderate to high mold spore levels. Additional areas identified, including an 8X100X8 hallway area and a resident bedroom are currently pending mold abatement work to be completed.

Based on LPA Jensen's visual inspection of the facility, observation of tarps on the ceiling and interviews conducted, the allegation of staff did not ensure the roof was fixed timely is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. It should be noted that the facility was cited for the roof leaks as they were discovered during an annual inspection conducted on 5/4/23. The roof leaks that occurred in January were not reported to the Department.

Based on a record review of the Mold Inspection Report and Microbial Investigation prepared by an environmental services company for the facility inspection completed 5/9/23, the allegation of staff did not ensure the facility was kept mold free is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

On 5/10/23 LPA Jensen sent the Licensee a written request via email to provide the environmental services company consent, in writing, to disseminate information and provide all reports directly to the Department. As of 5/23/23 at the time of this visit, written consent had not been given.

Deficiencies are being cited as a result of this complaint investigation and civil penalties are being assessed for repeat violations.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20230505082832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
CCR
87755(c)
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Inspection Authority of the Licensing Agency
...
The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours....This requirement was not met as evidenced by:
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The Licensee agrees to provide written consent to the environmental services company contracted with for mold abatement and provide a copy of said consent to maja.jensen@dss.ca.gov by 5/26/23.
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This requirement was not met as evidenced by LPA Jensen's written request that consent be provided on 5/10/23 which did not yet occur as of the date of this report. This poses a potential risk to the health, safety and personal rights of residents in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4