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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002976
Report Date: 12/13/2023
Date Signed: 12/13/2023 12:33:10 PM


Document Has Been Signed on 12/13/2023 12:33 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 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:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Amber GreeneTIME COMPLETED:
12:55 PM
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On 12/13/2023 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Amber Greene and explained the purpose of the visit. LPA Avila and Administrator toured facility together to ensure the health and safety of residents in care.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked area. Water temperature measured at 112 degrees. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene products. Common Areas: These included but at not limited to the living area, activity area, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no firearms or bodies of water on the premises. Record Review: Facility records are stored inaccessible to residents. The LPA reviewed five (5) staff, and five (5) resident files. All documents reviewed appeared complete and current. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record log. No errors observed during the medication review.

No deficiencies during todays visit. Exit interview conducted and copy of the report was provided to Amber Greene.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: (559) 974-4915
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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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