Golden Years Care Home I

Type of visit: Required - 1 Year

On 7/3/2026 at 9:50 am, Licensing Program Analysts (LPAs) Reza Jamaly and Christina Valerio arrived unannounced at the facility to conduct 1- year required inspection.LPAs initially met with staff one duty and explained the purpose of the visit. The administrator, Grace Bernardino was notified of the visit and arrived shortly after. Pascua Grace assisted with today’s visit. Administrator certificate #7002401740 is and will expire on 09/12/2027 . The current census is 6 with 2 facility staff. Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to six elderly residents, up to six may be non-ambulatory. Facility has a hospice waiver for 3 residents. Areas inspected include, but not limited to, the kitchen, dining area, resident units, resident bathrooms, laundry room, dining room and outdoor areas to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) non-ambulatory residents. LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed 6 bedrooms to be properly furnished with appropriate bedding and lighting. Adequate linen supply was observed. Grab bars and non-slip mat were observed to be stable and in good repair at this time. There are no bodies of water present. In the kitchen/dining area, LPAs observed at least 7-day nonperishable and 2-day perishable food items. LPA inspected medication storage a the corner of the kitchen, at least one medication drawer observed to be unlocked and an antiseptic (Isopropyl Alcohol) was observed inside it. Continues on LIC 9099C page 2 Page 2 LPA inspected 2 freezers and fridges no thermometers were observed a one of the fridges and freezer and one thermometer observed in another fridge and temperature reads 46.6 which is not in rage of 40-0 degree Fahrenheit. Technical Advisory provided to obtain thermometers for each refrigerator and freezer to ensure regulatory temperature is maintained at all times. Knives/sharps were locked in a drawer, but magnet lock observed to be loose. Administrator fixed it right away. Fire extinguishers observed and last serviced on 11/19/2025. Smoke detectors were observed and one of them was tested and was working. Hot water temperature was measured at the bathroom, it was measured 115.1 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. The last fire drill was conducted on April 2026. LPAs observed the facility has a has a public telephone in the Kitchen and the facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. LPA inspected outdoor areas, a pickaxe was observed during the physical inspection. LPAs observed a storage in the yard unlocked and a chainsaw was observed inside of it. Type A deficiency was cited for this observation. LPA reviewed 3 out of 6 resident medications and medication administration record (MAR) and it was complete. The first aid kit was checked and contained the required components. LPAs requested resident and staff files for review. LPAs reviewed 3 out of 6 resident files and they were complete. LPA reviewed 2 staff files, and it was complete. LPAs reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. Continues on LIC 9099C on page 3.. The following documents will be email to LPA by 07/07/2026 end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D pages. An exit interview was conducted with and a copy of these LIC 809 reports, LIC 809-D pages, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 3, 2026

Allegation investigated: Staff threw water on resident Staff slapped resident Due to lack of supervision, an adult went into residents room

On 12/31/2025, Licensing Program Analyst (LPA) Sommer Hayes arrived at this facility unannounced to conduct a complaint visit regarding the allegations noted above. LPA initially met with staff on duty Grace Pascua (S2) and stated the purpose of this visit. The administrator, Grace Bernardino, was notified and arrived shortly after. The purpose of this visit was to deliver complaint findings for the above allegations. Current census was 5. Allegation ONE: Staff threw water on resident Interviews were conducted with the alleged victim (R1), two additional residents (R2 and R3), the facility administrator, a Sutter PACE nurse, a Sutter PACE medical social worker, and the responsible party (RPP1). R1 denied that staff had ever poured or thrown water on them and responded “I don’t know” when asked if anyone had gotten them wet when they did not want to be. Continued on 9099C Unsubstantiated R2 and R3 both denied that staff had ever poured or thrown water on residents. R3 she said they receive bed baths and that the water may sometimes feel cold but stated that staff have never intentionally thrown water on them. The facility administrator denied the allegation and reported no concerns related to staff throwing water on residents. The Sutter PACE nurse and medical social worker both reported that they were not aware of any such incidents and had not observed any concerns during their regular visits. RPP1 reported that R1 had previously stated that someone had been rough with R1; however, RPP1 also acknowledged that R1 experiences delusions, embellishes events, and has cognitive impairment, and RPP1 did not personally witness any incident involving water and has never physically been in the facility. A review of facility records did not identify any documentation of incidents, injuries, complaints or reports related to staff throwing water on residents. Based on these interviews and records reviews there is no corroboration of this allegation. The statements obtained do not support that staff threw water on a resident. The preponderance of evidence standard is not met for this allegation. Therefore, the above allegation is found to be UNSUBSTANTIATED. Allegation TWO: Staff slapped resident Interviews were conducted with the alleged victim (R1), two additional residents (R2 and R3), the facility administrator, a Sutter PACE nurse, a Sutter PACE medical social worker, and the responsible party (RPP1). R1 did not recall that any staff member slapped them and responded with uncertainty (“I don’t know” or “I wish I knew”) when asked about physical harm. R2 and R3 both denied that any staff member had ever hit, slapped, or physically harmed residents. R3 specifically stated that no staff member had ever hurt them at the facility. The facility administrator denied the allegation and reported no concerns of physical abuse. The Sutter PACE nurse and medical social worker, both of whom have regular contact with the resident and the facility, stated that they were not aware of any physical abuse and did not believe the allegation occurred. Continued on 9099C RPP1 reported that R1 had stated that a caregiver was rough with R1; however, RPP1 also acknowledged that R1 experiences delusions, occasionally embellishes events, and has cognitive impairment. RPP1 did not personally witness any incident of physical abuse. A review of facility records did not identify any documentation of injuries or incident reports. Based on the interviews, there is no corroboration of the allegation, and the information obtained does not support a finding, by a preponderance of the evidence, that staff slapped a resident. The preponderance of evidence standard is not met for this allegation. Therefore, the above allegation is found to be UNSUBSTANTIATED. Allegation THREE: Due to lack of supervision, an adult went into residents’ room Interviews were conducted with the alleged victim (R1), two additional residents (R2 and R3), the facility administrator, a Sutter PACE nurse, a Sutter PACE medical social worker, and the responsible party (RPP1). R1 did not report that an unauthorized adult entered their room and did not identify any specific incident involving lack of supervision. R1 stated that they felt safe at the facility and responded “Not anymore” when asked if anyone made R1 feel uncomfortable but did not identify a person or event. R3 reported that staff and Staff 3 (S3) are authorized to enter their room and that on one occasion a male maintenance worker entered their room to repair flooring. R3 stated that the worker knocked prior to entering, communicated appropriately, and did not cause them any harm. R3 described the interaction as respectful and professional. R2 did not report any unauthorized entry into their room and did not raise concerns regarding supervision or unauthorized persons entering resident rooms. S3 denied that there had been any incidents involving unauthorized adults entering residents’ rooms due to lack of supervision. RPP1 reported that R1 had stated there was a man in her room; however, RPP1 also acknowledged that R1 experiences delusions, embellishes events, and has cognitive impairment, and RPP1 did not personally witness any adult entering R1’s room. The Sutter PACE nurse and medical social worker both reported that they were not aware of any incidents involving unauthorized adults entering residents’ rooms and had not observed concerns regarding lack of supervision during their regular visits. A review of facility records did not identify any documentation of incident reports of unauthorized entries, supervision concerns, or related incidents. Continued on 9099C Based on the interviews, there is no corroboration of this allegation, and the information obtained does not support a finding. The preponderance of evidence standard is not met for this allegation. Therefore, the above allegation is found to be UNSUBSTANTIATED. Based on interviews with the alleged victim, other residents, the responsible party, facility staff, and independent medical and social service professionals, there is insufficient evidence to support the allegations. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Grace Bernardino.the state’s words, verbatim · CDSS document, Dec 31, 2025 · control 27-AS-20250404114708

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Sommer Hayes and Arvin Villanueva conducted an unannounced Case Management- Annual Continuation visit today, 5/8/2025, continue with the Annual visit initiated on 5/7/2025. LPAs initially met with staff on duty and stated the purpose of the visit. The Administrator Grace Bernardino was notified of the visit and arrived shortly after. The LPAs continued with facility visit to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA conducted a review of medication review for 2 residents in care. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed based on this annual visit. Exit interview was conducted and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, May 8, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

An unannounced Annual visit was made by Licensing Program Analysts (LPAs) Sommer Hayes and Arvin Villanueva to this facility on 05/07/25 for an annual inspection. LPAs identified themselves upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPAs met with Administrator, Grace Bernadino and a brief interview followed. LPAs reviewed six resident files and three staff files. LPAs toured the facility with staff, Grace Pascua and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 76 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 120.7 degrees Fahrenheit in 1 of 2 bathrooms. LPAs observed 2 residents to be watching tv in their rooms, 1 sleeping in their room, and 1 arriving home from a doctor's appointment. LPAs observed first aid supplies, the carbon monoxide/smoke detectors, the fire extinguisher was last serviced on 11/21/24 by Jorgensen and was in compliance at the time of inspection. LPAs observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPAs observed a locked cabinet for the storage of medication. LPAs observed an inaccessible locked cabinets for the storage of cleaning solutions and knives. During today’s visit LPAs observed the following deficiencies: -2 Residents did not have an Admission Agreement on file for review. -A pickaxe broken in half with sharp wood pieces exposed and scissors were accessible to residents in the backyard. - 1 Resident did not have medical assessment record on file to review. Due to time constraints the Department will return at a later date to continue the annual inspection. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 5/1/24 at 3:30pm. LPA observed the Administrator Certificate is on the pending list with Department of Social Services (CCL) and has not been received yet. LPA met with Felisa Faytaren, Caregiver and stated the purpose of todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 2 may receive hospice care services. There is 0 residents receiving hospice care services during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 77*F which is within the required range of 68-85*F. The hot water temperature was measured at 120*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 residents and 1 staff files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-Submit Infection Control Plan-Submit Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, May 1, 2024