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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004502
Report Date: 09/18/2024
Date Signed: 09/18/2024 09:44:13 AM


Document Has Been Signed on 09/18/2024 09:44 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
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: 15DATE:
09/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joyce Martin TIME COMPLETED:
10:00 AM
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On 9/18/2024, LPA Kesha Lewis made an unannounced visit on this date to conduct a health and safety check. LPA met with staff Joyce Martin.

The temperature in the facility was a comfortable 77 degrees in the main area facility is clean and sanitary.

Staff state that R1 received all medication and belonging when being moved to facility on 8/26/2024. R1 has seen their physician to get continued medication and is in room E.

Health and Safety check today included overall safety of the facility including food supply, physical plant and staffing.

Exit interview and copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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