397003262-1-31-2023-27-AS-APAA-CNLMWD-20230131085811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397003262
Report Date: 01/30/2023
Date Signed: 01/31/2023 08:58:17 AM

Document Has Been Signed on 01/31/2023 08:58 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GOLDEN VALLEY RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	397003262
ADMINISTRATOR:	BAAY, LOVELYN		FACILITY TYPE:	740
ADDRESS:	625 SEQUOIA BOULEVARD		TELEPHONE:	(209) 830-8265
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	6	CENSUS: 3	DATE:	01/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nora Baay Casaverde		TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/30/2023 at 9:15am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a 1-Year annual visit. LPA Pascua was greeted by staff member, Nora Baay Casaverde and was asked to call the Facility Designated Administrator at this time to let them know that CCL was present. Shortly after, LPA Pascua was able to speak to the Facility Designated Administrator and explained the purpose of the visit. At this time the LPA was notified that the FDA could not make it to the facility and allowed the staff member to sign for paperwork. There was one other staff member on site, Nelia Baay. Current Census was 3. A tour of the facility was conducted., The administrator has an active Administrator Certificate #6018539740 and is valid until 08/14/2024. The interior of the physical plant was in good condition and sanitary. Fire extinguisher in the facility was present. The kitchen area was toured. LPA observed a 7-day non-perishable and 2 day perishable foods in the cabinets and refrigerator. Additional non perishable food supplies were identified in the cabinet in the hallway. LPA observed a locked centralized stored medication cabinet located. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. LPA observed bleach under the sink and reminded the staff that cleaning supplies need to be in a locked and made inaccessible to the residents. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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
	VISIT DATE: 01/30/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability Insurance

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Appeal rights were printed and a copy was given to the facility designated Administrator.

Exit Interview.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/31/2023 08:58 AM - It Cannot Be Edited

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: 01/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the cited above by the fire extinguisher located in the kitchen was expired on 1/05/2022, which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 01/30/2023
	Plan of Correction
1 2 3 4	The Licensee has agreed to purchase a new fire extinguisher today after the LPAs visit. The Licensee will provide a picture and proof of purchase to the LPAs email, arielle.pascua@dss.ca.gov by the POC date 1/30/2022.

Type A

Section Cited

CCR

87209(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not ensuring that all disinfectants are locked away and made inaccessible to the residents in care. LPA observed that there were disinfectants and bleach under the bathroom sink. This poses an immediate health, safety, or personal rights risk to the persons in care.
	POC Due Date: 01/31/2023
	Plan of Correction
1 2 3 4	During the visit, the LPA observed a staff member take out the bleach and disinfectant located under the bathroom sink and relocate them into a locked cabinet. POC will be cleared during this visit.

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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3