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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004502
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:54:53 PM


Document Has Been Signed on 06/13/2024 01:54 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 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: 13DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Joyce MartinTIME COMPLETED:
02:00 PM
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On 06/13/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Joyce Martin and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds a current certificate and expires on November 04, 2024. The facility is licensed for fifteen ambulatory residents, which one can be non-ambulatory . There are currently 13 residents who reside at this facility.

The LPA Martinez toured the facility with Joyce Martin on 06/13/2024 at 1:00 PM.

The facility has a natural disaster plan and the last fire drill was on February 10, 2024. LPA Martinez reviewed five resident files and 3 staff files, which were maintained. LPA Martinez requested a copy of liability insurance and fire inspection, which will be emailed to LPA Martinez. LPA Martinez reviewed two medication administration records (MAR), and both MARs were maintained. The facility has a first aid kit, and medication is stored in locked cabinet. The smoke detectors, carbon detectors, and fire extinguishers were in good repair. The facility bathrooms, kitchen, bedrooms, laundry room, and common areas were furnished and sanitary. The facility has an adequate food supply. The facility water temperature measured 105 degrees, and facility temperature measured at 73 degrees.

Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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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