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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003262
Report Date: 12/02/2021
Date Signed: 12/10/2021 02:06:24 PM

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 VALLEY RESIDENTIAL CARE FACILITYFACILITY NUMBER:
397003262
ADMINISTRATOR:BAAY, LOVELYNFACILITY TYPE:
740
ADDRESS:625 SEQUOIA BOULEVARDTELEPHONE:
(209) 830-8265
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:6CENSUS: 4DATE:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Lovelynn Bay,, Administrator.TIME COMPLETED:
03:02 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Norma Casaverde, Caregiver (S1) met with Lovelynn Bay,, Administrator (AD).

LPA and S1, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.

Upon entry, sign in sheets were observed to document date and visitors name. Sign in sheets did not include symptom screening for reporting requirements to public health officer and contact tracing. All persons in facility fully vaccinated LPA observed resident practicing social distancing. LPA observed 30 days PPE supply.

LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 105.4 degrees in residents bathroom with the S1 which is in required range of 105 to 120 degrees.
LPA observed sharps and toxins not locked.
Last Fire Drill conduced dated 2/3/2020 Fire extinguisher maintained 7/01/2021.
Fire alarm and carbon monoxide functional. LPA and S1 observed centrally stored medications.
LPA reviewed 3 staff and 4 resident files. Resident emergency contact complete. LPA observed all staff files complete. Administrator Certificate valid until 8/20/2022.
Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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 VALLEY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 397003262
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited

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87705(f)(1)
The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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This requirement is not met as evidenced by: Based on observation, the licensee did not ensure sharp tools and toxins. LPA observed an unlocked knife in top drawer next to sink. Lock under sink where there were toxins in kitchen not latched. Lock in kitchen where the sharps were kept not locking properly. This poses an immediate health and safety risk to residents in care.
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Type B
12/13/2021
Section Cited

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80023(d)(2)
Disaster and Mass Casualty Plan - Disaster drills shall be conducted at least every six months. The drills shall be documented and the documentation maintained in the facility for at least one year.
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This requirement was not met as evidenced by records reviewed, care home last conducted a fire drills on 2/3/2020. This poses a potential safety risk to the 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 VALLEY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 397003262
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2021
Section Cited

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87464 (f)(1) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
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This regulation was not met by evidence by: A sign-in policy upon entry was not enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3