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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601511
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:51:36 PM


Document Has Been Signed on 05/06/2022 01:51 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:GOLDEN HILLS HOME CAREFACILITY NUMBER:
075601511
ADMINISTRATOR:DEL CASTILLO, GERLITA B.FACILITY TYPE:
740
ADDRESS:9474 ALCOSTA BLVDTELEPHONE:
(925) 875-9800
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 5DATE:
05/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Fathma Ansari, AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
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On 5/6/2022 at 10:00 AM, Licensing Program Analyst (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct a Case Management concurrently with a Pre-licensing Inspection. Upon arrival, LPAs were greeted by Care Staff, Rodora Suzon. Administrator, Fathma Ansari later arrived at 10:24 AM.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
  • At 10:30 AM, LPAs observed two knives being stored inside dishwasher accessible to residents. Deficiency cleared during visit. Staff removed both knives and locked it away.
  • At 10:33 AM, LPAs observed laundry detergent unlocked placed above laundry machines. Deficiency cleared during visit. Staff removed detergents from shelf and locked it away inside a cabinet.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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Document Has Been Signed on 05/06/2022 01:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GOLDEN HILLS HOME CARE
FACILITY NUMBER: 075601511

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2022
Section Cited

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CARE OF PERSONS WITH DEMENTIA
(f)The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Based on LPAs observation, Licensee did not comply with the regulations cited above. LPAs observed unlocked knives in dishwasher which poses an immediate health and safety risk to persons in care.
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Type A
05/07/2022
Section Cited

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CARE OF PERSONS WITH DEMENTIA
(f)The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Based on LPAs observation, Licensee did not comply with the regulations cited above. LPAs observed unlocked laundry detergent above laundry machine which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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