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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 09:45:24 AM


Document Has Been Signed on 09/21/2023 09:45 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 - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Amber GreeneTIME COMPLETED:
10:05 AM
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On 09/21/2023 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to deliver an amended complaint, COMPLAINT CONTROL NUMBER: 59-AS-20230728163040, that was previously recorded on 09/07/2023. LPA Avila met with Amber Greene and explained the purpose of the visit.

LPA Avila delivered an amended 9099 to reflect the appropriate deficiencies LPA observed during the complaint investigation that was previously recorded on 09/07/2023.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the amended 9099D. 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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