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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001613
Report Date: 11/29/2022
Date Signed: 11/30/2022 11:03:34 AM

Document Has Been Signed on 11/30/2022 11:03 AM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN ACRES HOME AND CARE IIFACILITY NUMBER:
397001613
ADMINISTRATOR:MARIVIC TEANO-CHUAFACILITY TYPE:
735
ADDRESS:2002 E. HARDING WAYTELEPHONE:
(209) 943-5420
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 15CENSUS: 13DATE:
11/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Catherine CalairoTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA'S) Kesha Lewis and Albert Johnson conducted an unannounced Case Management visit to follow up on an AWOL incident, which occurred on 10/31/22. LPA'S explained purpose of visit to staff.

On 10/31/22 Resident 1 (R1) AWOL'd from the facility, and showed up at his mother’s house on 11/04/2022. R1 had no medication from 10/31/22-11/09/2022. On 11/10/2022 R1 and his father came to pick up his medication from the facility. Medication errors in the form of missed medication doses have occurred on 10/31/22-11/09/2022 and R1'S Physician was not notified by the facility of the missed medication nor was the department sent an incident report regarding missed medication for R1. The medication administration record for R1 has not been filled out for the month of November up until today 11/29/2022. Copy taken.

LPA'S reviewed R1'S file and LIC 602 (Physician's report) and R1 is able to leave the facility unassisted. Copy taken.

LPA'S conducted a tour through facility with staff to check fire clearance. LPA'S observed the Ansul system had not be serviced since 1995. There is a annual inspection and a (5) five year inspection that should be conducted. Photo taken.

Deficiencies were observed and cited from the California Code of Regulations, Title 22.

Exit interview conducted with Staff and a copy of report was left at facility. Appeal rights given

Kesha.lewis@dss.ca.gov
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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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Document Has Been Signed on 11/30/2022 11:03 AM - It Cannot Be Edited


Created By: Kesha Lewis On 11/29/2022 at 11:19 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN ACRES HOME AND CARE II
FACILITY NUMBER: 397001613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
11/30/2022
Section Cited
CCR
80020

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on: Observation.
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Administrator will ensure that the fire equipment listed is inspected or a plan is made and sent to CCL by the POC date indicated. Licensee/Administrator shall send picture of the new tags as proof and submit Statement of Compliance by POC date.
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The facility failed to maintained in conformity with the regulations adopted by the State Fire Marshal. The "Fixed System" or "Ansul System", this system is scheduled for a annual maintenance and was last serviced on 01/1995.This poses an immediate Health and Safety risk to residents in care.
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Type A
11/30/2022
Section Cited
CCR80075(b)

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The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
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By 11/30/2022 the Administrator shall evaluate the facility's medication distribution practices and submit a revised program plan on medication management to avoid any further medication errors.
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LPA'S discovered through records review that R1 had not received medication from 10/31/22-11/09/22. This poses an immediate Health and Safety risk to residents in care.
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Further, additional medication training shall be completed by all staff who handle residents medications by 11/30/22.
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 King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2022 11:03 AM - It Cannot Be Edited


Created By: Kesha Lewis On 11/29/2022 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN ACRES HOME AND CARE II
FACILITY NUMBER: 397001613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2022
Section Cited
CCR
80061

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Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.(A) Death of any client from any cause.(B)In a residential facility, death of any client as a result of injury, abuse, or other than natural causes, regardless of where the death occurred. This includes a death that occurred outside the facility such as at a day program, workshop, job, hospital, en route to or from a hospital, or visiting away from the facility.

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Administrator will review Title 22 Regulations Section 87211 and have an In-service training with all Staff regarding Reporting Requirements. Administrator will submit a written plan ensuring that incidents are reported to the CCL office as required according to the Regulation. Signatures of all
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This requirement was not meet as evidenced by records review LPA'S reviewed R1'S file and found the MAR incomplete for the month of November,, and no incident report notifying the department could be found. This poses a health and safety risk to residents in care.
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Staff from the training must be submitted to CCL after training is complete. The plan is due by the POC date of 12/09/22.

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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 King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022


LIC809 (FAS) - (06/04)
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