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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001613
Report Date: 09/11/2024
Date Signed: 09/11/2024 02:19:33 PM

Document Has Been Signed on 09/11/2024 02:19 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN ACRES HOME AND CARE IIFACILITY NUMBER:
397001613
ADMINISTRATOR/
DIRECTOR:
MARIVIC TEANO-CHUAFACILITY TYPE:
735
ADDRESS:2002 E. HARDING WAYTELEPHONE:
(209) 943-5420
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 15CENSUS: 15DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Marivic Teano-ChuaTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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On 9-11-2024 at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Marivic Teano-Chua and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common areas, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an adult residential facility with a current census of 15. Facility has 8 bedrooms and 4 bathrooms for resident use. One extra room is for staff use. Facility has a dining area off the kitchen. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 15 ambulatory residents, 0 non ambulatory residents, 0 hospice, and 0 bedridden. The facility has an approved infection control plan in place.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 76*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 12-2-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff.

During this inspection 5 resident files and 3 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances.

{Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN ACRES HOME AND CARE II
FACILITY NUMBER: 397001613
VISIT DATE: 09/11/2024
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LPA completed 3 resident interviews and 3 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility does not contain any bodies of water. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts monthly fire drills.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a copy of this report was given to Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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