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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004502
Report Date: 05/30/2023
Date Signed: 11/09/2023 12:03:16 PM


Document Has Been Signed on 11/09/2023 12:03 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, 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:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marivic Chua, Administrator/LicenseeTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date, 05/30/2023.. LPA met and toured with Administrator, Marivic Chua Licensee. The administrator currently holds a certificate (#6021613740) that expires on 11/04/2024. .

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 10 total bedrooms, of which 9 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 70 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 106 degrees Fahrenheit. Night lights are maintained in hallways and passages to nonprivate bathrooms. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.
There were 3 of 3 staff files reviewed and 2 of 15 client files reviewed.

No deficiencies issued during the visit.
Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
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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