397001613-9-7-2022-27-AS-RWAE-CJ2PKT-20220907112339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397001613
Report Date: 09/07/2022
Date Signed: 09/07/2022 11:23:48 AM

Document Has Been Signed on 09/07/2022 11:23 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GOLDEN ACRES HOME AND CARE II		FACILITY NUMBER:	397001613
ADMINISTRATOR:	MARIVIC TEANO-CHUA		FACILITY TYPE:	735
ADDRESS:	2002 E. HARDING WAY		TELEPHONE:	(209) 943-5420
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95205
CAPACITY:	15	CENSUS: 15	DATE:	09/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marivics Teano-Chua - Administrator		TIME 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	Licensing Program Analyst (LPA) Ruth Wallace arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection visit. LPA was met by staff who informed Administrator of the LPA' s visit. LPA explained the purpose of the visit and staff accompanied LPA on the facility inspection. LPA and staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 15 bed facility with a current census of 15. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID-19 precautions in place including social distancing noted. Medications and toxins noted to be locked to residents in care. Resident rooms were sanitary and had the required furniture and furnishings. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. LPA also conducted the infection control domain tool. LPA observed the temperature inside the facility was measured at 74F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 110.3F, which is within the regulatory range of 105 - 120 degrees F. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID-19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Smoke and carbon detectors were in good repair. Fire extinguishers are current and expire on 11/30/2022. Continued on 809-C

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN ACRES HOME AND CARE II	FACILITY NUMBER: 397001613
	VISIT DATE: 09/07/2022

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Continued from 809 - Page 2

LPA reviewed five (5) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.
LPA reviewed five (5) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

LPA Wallace requested updated copies via email to LPA by October 18, 2022: Updated Program and Plan of Operation, LIC 308 - Designation of Administrator, LIC 500 - Personnel Report and, LIC 610D Emergency Disaster Plan.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC809 (FAS) - (06/04)

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