<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001724
Report Date: 09/20/2021
Date Signed: 09/20/2021 11:57:57 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GOLDEN YEARS RESIDENTIAL HOME CAREFACILITY NUMBER:
515001724
ADMINISTRATOR:DEJEU, CLAUDIUFACILITY TYPE:
740
ADDRESS:837 ALLEN WAYTELEPHONE:
(530) 822-9463
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY:6CENSUS: 6DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Claude DejeuTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
9/20/2021 9:15 AM Licensing Program Analyst (LPA’s) Dawn Keane and Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA’s met with administrator (AD) Claude Dejeu and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. Additionally, LPA’s Keane and Valencia were screened by AD.

LPA’s Keane, Valencia and toured facility with AD to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, three (3) bathrooms, kitchen, storage areas front yard and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA’s Keane, Valencia and the AD completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report was emailed to AD.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Dawn KeaneTELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2