397003262-3-18-2025-27-AS-APAA-DEVVSK-20250318164139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397003262
Report Date: 03/18/2025
Date Signed: 03/18/2025 04:41:53 PM

Document Has Been Signed on 03/18/2025 04:41 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 VALLEY RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	397003262
ADMINISTRATOR/ DIRECTOR:	BAAY, LOVELYN		FACILITY TYPE:	740
ADDRESS:	625 SEQUOIA BOULEVARD		TELEPHONE:	(209) 830-8265
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	03/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Lovelyn Baay		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

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 03/18/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by Facility Designated Administrator (FDA), Lovelyn Baay and explained the purpose of the visit. There were two other staff members present, Nelia Baay and Nora Bay Casaverde. Current Census was 2. A brief interview with FDA Baay was conducted. This facility is licensed to serve 6 elderly residents. 3 out of 6 residents any be non-ambulatory. This facility also has a hospice waiver for 3 residents. LPA reviewed 2 staff files. 2 out 2 staff files are complete and up to date. LPA reviewed 2 resident files. The administrator has an active Administrator Certificate #7005498740 expires 08/14/2026. A tour of the facility was conducted. Carbon monoxide and smoke alarms were present and were observed to be in good repair. Fire extinguisher in the facility was present and was purchased with attached receipt 11/21/2024. 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. 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. 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.

Lisa Rios	TELEPHONE: (916) 969-9685
Arielle Pascua	TELEPHONE: (916) 862-5907
	DATE: 03/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN VALLEY RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 397003262
	VISIT DATE: 03/18/2025

NARRATIVE

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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

An technical violation was provided for Section 87411(c).

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.

Exit interview was conducted.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

LIC809 (FAS) - (06/04)

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