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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004502
Report Date: 06/07/2022
Date Signed: 06/08/2022 09:35:26 AM


Document Has Been Signed on 06/08/2022 09:35 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 PINE GUEST HOMEFACILITY NUMBER:
397004502
ADMINISTRATOR:MARIVIC TEANO-CHUAFACILITY TYPE:
740
ADDRESS:314 WEST PINE STREETTELEPHONE:
(209) 334-6441
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:15CENSUS: 15DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Marivic Teano - Chua, AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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On 06/07/2022 at 1:25 PM, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Caregiver, Angelita Yapo and later met with Administrator, Marivic Teano- Chua at 2:45 PM. LPA explained the purpose of today’s inspection and was allowed entry into the facility that is licensed to serve a total capacity of 15 residents, which one may be non-ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.8 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

LPA observed smoke detectors are interconnected with the fire department. LPA observed sprinklers installed throughout the facility. First aid kit was observed to be complete. LPA reviewed 5 resident files and 5 staff record files.

LPA observed the following deficiencies:
- Fire Extinguisher was last serviced on May 27, 2021. Based on Fire Department, fire extinguisher should be serviced annually.
- LPA observed carbon monoxide detector was not present at the facility. Based on Administrator, the facility has not installed the carbon monoxide detector yet.
The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Administrator. Appeal rights and a copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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 06/08/2022 09:35 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 PINE GUEST HOME
FACILITY NUMBER: 397004502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview, the licensee did not comply with the section cited above in 1569.311. LPA observed carbon monoxide is not present at the facility. Based on Administrator interview, the facility did not install carbon monoxide, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2022
Plan of Correction
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Administrator agreed to purchase carbon monoxide and submit proof to CCLD by POC date.
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(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:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 87202(a). LPA observed fire extinguisher last serviced on May 27, 2021 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Administrator agreed to service fire extinguisher and submit proof to CCLD by POC date.

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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2