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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001724
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:34:33 PM


Document Has Been Signed on 08/22/2024 03:34 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 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:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Claudiu DejeuTIME COMPLETED:
03:45 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Administrator Claudiu Dejeu.

This facility has six private resident rooms, one staff room, and three full common bathrooms. There are two sitting areas and the kitchen and dining are in the back. There is a laundry room and storage area in the garage. The backyard was inspected and the gate is on the same side as the garage. The medications and files are kept locked in the hallway. No health and safety concerns were found during the tour.

Three resident records and two staff records were reviewed. Staff roster was reviewed and adjusted.

Multiple topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by September 25, 2024:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
-LIC 610 emergency disaster plan.

No deficiencies were observed.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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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