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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701254
Report Date: 05/13/2024
Date Signed: 05/24/2024 09:15:47 AM

Document Has Been Signed on 05/24/2024 09:15 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 PRIDE SERVICES CARE-NIGHTINGALEFACILITY NUMBER:
502701254
ADMINISTRATOR/
DIRECTOR:		PENNY, TYRONEFACILITY TYPE:
735
ADDRESS:3221 NIGHTINGALE DRTELEPHONE:
(209) 380-6191
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 4CENSUS: DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Prasheila SinghTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 5/10/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. There was no one available at the facility. LPA Jensen contacted the Licensee by phone who advised the facility has not accepted their first client yet and as a result the annual would be need to be scheduled. On 5/13/24 LPA Jensen returned to complete the annual inspection. There are currently no clients in care.

LPA Jensen toured the exterior and interior of the facility. The grounds have been maintained in the front yard. The window screens are in good repair. There is outdoor furniture available for client use. There are no bodies of water on the grounds. The interior of the facility was observed to be sanitary and free of odor. There are three bedrooms. Lighting and furniture was observed to be adequate throughout. LPA Jensen tested the water temperature in the hallway bathroom and observed it to be 119 degrees Fahrenheit which falls within the required regulatory range of of 105-120 degrees Fahrenheit. The thermostat was set at a comfortable temperature. LPA Jensen reviewed observed the smoke detector and carbon monoxide detector to be in good working order. The fire extinguisher was newly purchased and is in compliance. There is emergency lighting, food and water available. The first aid kit was observed to be complete. All required postings were prominently displayed on the wall in the dining room area. Technical assistance was provided in the areas of infection control plans and self-determination as related to the Home and Community Based Services rules.

The facility was determined to be in substantial compliance. The Licensee will notify the Department if and when the first client is accepted. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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