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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317215
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:02:19 PM


Document Has Been Signed on 07/20/2023 01:02 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:
07/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maravic Teanu-ChuaTIME COMPLETED:
01:15 PM
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On 7/20/23 at approximately 10:30am Licensing Program Analyst Maja Jensen arrived at facility unannounced to conduct a case management in order to verify the Plan of Correction has been completed for deficiencies cited on 5/23/23 related to the facility roof and interior mold. LPA Maja Jensen met with Licensee Maravic Teanu-Chua and explained the purpose of today's visit.

Mold abatement work and ceiling repairs have been conducted for rooms C and M. LPA Jensen reviewed an estimate and the corresponding invoice from Indoor Restore Environmental Services for mold abatement work in room C and M. LPA Jensen also reviewed an email from Indoor Restore Environmental Services dated 6/21/22 which states there was no evidence found of elevated mold presence in room D and the associated Air Sampling Analysis Results.

LPA Jensen reviewed a Certificate of Clearance dated 5/26/23 valid for 10 years related to the post mold abatement testing for room C and M.

The Licensee was unable to locate the Air Sampling Analysis Results for the hallway and has agreed to forward verification to LPA Jensen that hallway did not require mold abatement by 7/24/23.

A letter of Citations for Deficiencies Cleared was generated for the violation of California Code of Regulations (CCR) 87755(c) cited on 5/23/23. A letter of Citations for Deficiencies Cleared was also generated for the violation of CCR 87211(a)(1)(D) cited on 5/23/23.

A letter of Citations for Deficiencies Cleared will be generated for the violation of CCR 87303(a) upon receiving verification that mold abatement was not necessary for the hallway from the Environmental Services mold abatement contractor.

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: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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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