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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 03:49:39 PM

Document Has Been Signed on 09/11/2024 03:49 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:13 PM
MET WITH:Marivic Teano-ChuaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 9-11-2024 at 3:13pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an absence without leave (AWOL). LPA met with Licensee Marivic Teano-Chua and explained the purpose of the visit. LPA conducted brief interview with Licensee and reviewed facility file documentation including incident report dated 8-26-24, sign in/sign out sheet for residents, physician report for resident1 (R1), and police report inquiry dated 8-22-24.

Based on interview and record reviews, it was revealed that on 8-22-24, R1 signed out facility at approximately 8:05am with a destination noted on the sign out sheet with an expected return time of 9:00pm. R1 did not return by 9:00pm and Licensee notified local police department to file a missing persons report at approximately 9:20pm. R1 was found by local law enforcement on 9-4-24 and brought to crisis center for evaluation, and not expected to return to facility. Licensee sent incident report to licensing agency within regulatory required time frame after incident. Incident report stated in part that "He was told...AWOL behavior is not tolerated at the facility and immediately be evicted." However, based on interview, Licensee has not began eviction procedures and has no plans for eviction.

No citations are issued as a result of today's case management. An exit interview was conducted with Licensee and a copy of this report was provided to Licensee.
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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