Golden Years Retreat

Type of visit: Post Licensing

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required Post Licensing Visit and was greeted by Administrator Dawit Belaineh. Golden Years Retreat Inc. is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for six (6) non-ambulatory residents. The facility has a Hospice Waiver for two (2) residents. The facility has a Dementia program on file. The facility began admitting residents in 6/2026. Upon arrival, LPA was informed that there is one (1) resident in care. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 8:55 AM, LPA toured the facility. All exits were clear and unobstructed. The facility's two (2) fire extinguishers were last serviced and tagged on 6/29/2026. The facility was sufficiently lighted. LPA inspected four (4) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 6/6/2026. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. Continued on 809-C... ...Continued from 809 At approximately 10:05 AM, LPA reviewed one (1) resident file. One (1) of one (1) resident's file was found to be well organized and thorough with all required documentation. LPA reviewed one (1) staff files. One (1) of one (1) staff's files was found to be well organized with all required documentation including First Aid and CPR certification. LPA audited Medication for one (1) resident. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items. Dawit Belainehr’s Administrator Certification 7039846740 is current with an expiration date of 10/28/2026. LPA requested the following documents be submitted to Community Care Licensing by 7/30/2026: LIC 500 Personnel Report LIC 308 Designation of Responsibility (once designate is hired) The facility is in compliance. No deficiencies cited during today's visit. Exit interview conducted. Copy of report and discussed and provided to Administrator Belaineh . Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 2, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

At approximately 8:45 AM, Licensing Program Analyst (LPA) Robert Frank arrived for a scheduled visit to conduct a pre-licensing inspection and was greeted by Licensee/Applicant/Administrator, Dawit Belaineh. This pre-licensing inspection is being conducted for an initial licensing of a Residential Care Facility for the Elderly (RCFE). Fire Clearance has been approved for six (6) non-ambulatory residents. All bedrooms are approved for non-ambulatory use. Applicant did not ask for approval for bedridden residents by the local fire department. At approximately 9:05 AM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. Applicant had non-slip mats and grab bars in place. LPA observed a supply of clean linens, and paper products available for residents. Residents' bedrooms have all the appropriate furnishings as outlined in Title 22 regulations. LPA observed dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in locked cabinets. Applicant agrees to keep magnets and keys to these locked areas in facility safe secured and inaccessible to residents in care. Licensee agrees to maintain at least two days of perishable foods and one week of non-perishable foods and an emergency water supply. The required posters were not observed hanging in the facility. Licensee/applicant will purchase a long-term care ombudsman poster and the PUB 475 Facility Complaint poster which will be hung on a wall in a common area prior to resident occupancy. Applicant has posted a copy of their admissions agreement and emergency disaster plan in a common area of the facility. Continued on 809-C... ...Continued from 809 The facility currently has the Applicant associated to facility in Guardian and will hire an additional staff members once license is approved. Applicant has been informed of association and staff transfer process. Applicant will provide an ipad/computer for residents to use. Facility phone/land line was observed to be operational. Facility has a designated locked cabinet for centrally stored medications. LPA observed a first aid kit and other emergency supplies. LPA recommended that Applicant add additional, age appropriate activities for elderly residents. Facility has multiple fire extinguishers, which are brand new and fully charged. Smoke and Carbon Monoxide detectors were tested and observed to be operational during inspection. LPA reviewed a facility sketch which was observed to accurately reflect the floor plan. The backyard features a shaded patio area for resident use. Windows, screens, and blinds were all observed in good repair. Prior to admitting residents, applicant will: remove bricks and tiles from back yard patio area; purchase night lights for hallways; purchase individual bins so that resident's medications are separated; add a door lock to the laundry area; add a door lock to the garage; remove half-rails from all beds; finish minor repair work in closet of bedroom #4 as marked on facility drawings. LPA and Licensee/Applicant discussed the following items: Hospice Waiver - Applicant to apply for a waiver if it's decided they want hospice care in the facility. Requirements for a Hospice Waiver and a Hospice Exception along with copies of 87632 Hospice Care Waiver & 87633 Hospice Care of Terminally Ill Residents regulation were provided to Licensee applicant. Guardian background clearances and associations Updated Dementia regulations. LPA discussed Licensee/Applicant providing a Dementia Care program in the future. Technical Support Program (TSP). Licensee/Applicant expressed interest in the Department's TSP. LPA will submit a request for Technical Support on behalf of the Licensee/Applicant. LPA provided Licensee/Applicant requirements for a Plan of Operation update needed to have video surveillance at the facility. Continued on 809-C2... ...Continued from 809-C Component III orientation was conducted at facility with Dawit Belaineh. Dawit Belaineh’s Administrator Certification 6072519740 is current with an expiration date of 10/28/2026. Applicant will submit proof of liability insurance once facility has been licensed. No Deficiencies given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Facility for the Elderly (RCFE). LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status. Exit interview conducted. Copy of report discussed and provided to Applicant/Administrator Belaineh. Signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Feb 19, 2026

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.