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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002976
Report Date: 09/21/2023
Date Signed: 09/21/2023 09:49:36 AM


Document Has Been Signed on 09/21/2023 09:49 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLDEN OAKS SENIOR LIVINGFACILITY NUMBER:
455002976
ADMINISTRATOR:WILLIAMS, KENNETHFACILITY TYPE:
740
ADDRESS:779 KERRYJEN CT.TELEPHONE:
(530) 223-1538
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:26CENSUS: 10DATE:
09/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Amber GreeneTIME COMPLETED:
10:10 AM
NARRATIVE
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On 09/21/2023 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a case management visit. LPA Avila met with Amber Greene and explained the purpose of the visit.

On 04/26/2023 R1 exited the facility alone and unassisted in the late evening and R1 was found later by staff. LPA interviewed staff and they stated R1 had walked out of the facility and was found some time after.

On 04/28/2023 R1 exited the facility again alone and unassisted and was found down the street at the corner of the block. LPA interviewed Facility Manager (S1) and S1 stated that it took staff 10 minutes to realize R1 had left the facility and an additional 10 minutes to locate R1 down the street. R1 was missing for approximately 20 to 30 minutes.

The facility did not report the two incidents to the Department within the required time frame. The Department was notified of the two incidents three months later in July of 2023 and both incidents occurred in April of 2023.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the 809-D. Exit interview conducted with Amber Greene and a


copy of the report along with appeal rights were provided.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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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Document Has Been Signed on 09/21/2023 09:49 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GOLDEN OAKS SENIOR LIVING
FACILITY NUMBER: 455002976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
87211(a)(D)

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87211(a)(D) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to…Any incident which threatens the welfare, safety or health of any resident or unexplained absence of any resident. This requirement is not met as evidence by:
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Licensee had a training with all staff that was held by the local Ombudsman and went over the eloping procedures and how to report all incidents in the facility and send them to the Department.
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Based on interviews and record review, the licensee did not submit incident reports to the Department regarding a resident’s unexplained absence at the facility when resident left the facility alone and unassisted in two seperate incidents.
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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: Lauren CrockerTELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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