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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317215
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:46:37 PM


Document Has Been Signed on 08/02/2023 12:46 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 CAREFACILITY NUMBER:
390317215
ADMINISTRATOR:MARICEL YAPOFACILITY TYPE:
740
ADDRESS:1101 CALIFORNIA STREETTELEPHONE:
(209) 838-3405
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:26CENSUS: DATE:
08/02/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marivic Teanu-ChuaTIME COMPLETED:
11:00 AM
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An Informal Conference was conducted today at the Sacramento Regional Office via Microsoft Teams. Present for the meeting was Licensee, Marivic Teanu-Chua, Repair and Maintenance Consultant, Jon Chua, Licensing Program Manager, Liza King, Supervisor for Board & Care, Employment and Supportive Housing with San Joaquin County Behavioral Health Services, Lincoln Ellis, Care Provider Liason, Amy Rivera and the writer of this report Licensing Program Analyst, Maja Jensen.

The purpose of the informal conference was to address the facility’s compliance issues. The Department has concerns stemming from site inspections on multiple occasions during this current year of 2023 and a substantiated complaint regarding mold in the facility that has not yet been remediated.

On or around January of 2023, the facility had a roof leak that was not reported and subsequently developed toxic mold. Issues discussed during the meeting under the California Code of Regulations (CCR) were:

80087(a) – Building and Grounds-The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

87405(h)(5)-Administrator-Qualifications and Duties-The administrator shall have the responsibility to:

…Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs…

87468.1(a)(2) Personal Rights of Residents in All Facilities-… To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

In an effort to support the facility maintaining substantial compliance with CCR the Department is developing a plan with the licensee to address the causes for concern.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN ACRES HOME AND CARE
FACILITY NUMBER: 390317215
VISIT DATE: 08/02/2023
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Plan to address compliance concerns:

The facility will complete mold remediation and any associated work to the mold remediation such as ceiling repairs and conduct clearance testing of work and non-work areas by 9/14/23. The facility will also provide a certificate of clearance for areas where mold remediation was conducted and all sample results for areas tested including work and non-work areas.

The Department will provide additional case management visits.

Deficiencies are being cited from the CCR. Failure to correct deficiencies will result in the assessment of civil penalties.

An exit interview was conducted and during the course of the exit interview the licensee was told that this Informal Conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference that could then lead to referral to the Department's legal division. A copy of this report was emailed to the Licensee for electronic signature.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/02/2023 12:46 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: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
80087(a)

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Buildings and Grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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The Licensee agrees to complete mold abatement and remediation and all work associated with the mold abatement and remediation such as ceiling repairs by a licensed contractor by 9/14/23 and will email the invoice to maja.jensen@dss.ca.gov by POC due date.
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Based on LPA Jensen's review of the supplemental invoice # 47973 for mold abatement from Indoor Restore and Licensee's own admission that mold abatement in the facility hallways has not been completed. This poses a potential risk to the health, safety and personal rights of residents in care.
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Type B
09/14/2023
Section Cited
CCR87468.1(a)(2)

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Personal Rights
Residents in all residential care facilities for the elderly shall have all of the following personal rights:...
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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The Licensee agrees to provide a certificate of clearance for all areas where mold abatement work was conducted and all sample results for clearance testing of work and non-work related areas including Dining Room, Hallway by Dining Area, Piano Room, Front Desk Lobby Area, Back Exit Hallway, Room E.
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Based on LPA Jensen's review of the supplemental invoice # 47973 for mold abatement from Indoor Restore and Licensee's own admission that mold abatement in the facility hallways has not been completed. 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: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/02/2023 12:46 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: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2023
Section Cited
CCR
87405(h)(5)

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Administrator Qualifications and Duties
The administrator shall have the responsibility to:
…Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs…This requirement was not met as evidenced by:
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The Licensee agrees to have the Administrator and the co-Administrator sign an attestation that CCR 87405 has been read, understood and will be complied with by 8/3/23
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Based on the License's inability to provide evidence that the hallways have been addressed for mold remediation during the course of a site visit on 7/20/23 and based on LPA Jensen receiving notification that the Licensee was provided an estimate for the work required on 5/25/23. 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: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4