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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003262
Report Date: 02/04/2022
Date Signed: 02/04/2022 11:13:08 AM

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:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Nora Casaverde - CaregiverTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Required Annual/ Infection Control visit on this date. LPA was greeted by Nora Casaverde, Caregiver (S1) and explained purpose of visit. Administrator Certificate expires 8/20/2022.

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 expires 7/01/2022.
Fire alarm and carbon monoxide functional. LPA and S1 observed centrally stored medications.
LPA reviewed 3 staff and 3 resident files. Resident emergency contact complete. LPA observed all staff files complete. S1 was missing current first aid certificate. S3 was missing a current health screen and TB test.
Immediate Civil Penalty of $500.00 for individual not fingerprinted visiting in facility.
Per California Code of Regulations, Title 22 Division 6, Chapter 8, the following deficiencies are being cited today in violation of California Code of Regulations. If deficiencies are not corrected by the noted due date civil penalties may be assessed.

Exit interview held with S1 and a copy of reports, appeal rights, and civil penalty left at facility..

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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 4
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: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(d) All individuals subject to a criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation an individual visiting the facility on a regular basis is not fingerprint cleared, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2022
Plan of Correction
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Licensee agrees to submit a plan to LPA via email by POC date of 2/5/2022 stating all individuals in the facility will be fingerprint cleared prior to the individual's employment, residence, or intial presence in the facility.
ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, staff (S1) is missing current first aid and cardiopulmonary resuscitation (CPR), the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2022
Plan of Correction
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Licensee agrees to submit to LPA via email S1's current copy of first aid and CPR by POC date of 2/09/22.
ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation Staff (S3) is missing a current health screen and TB test, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2022
Plan of Correction
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Licensee agrees to submit to LPA via email S3's new health screen and TB results by POC date of 2/09/2022.
ruth.wallace@dss.ca.gov
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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4