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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200381
Report Date: 06/03/2022
Date Signed: 06/03/2022 04:38:03 PM

Document Has Been Signed on 06/03/2022 04:38 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 AURORA HEALTHCARE INC.FACILITY NUMBER:
079200381
ADMINISTRATOR:MARIA THERESA B RIVERAFACILITY TYPE:
735
ADDRESS:2709 VISTA COURTTELEPHONE:
(408) 207-5172
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 6DATE:
06/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Miriam Cruz Rodriguez, CaregiverTIME COMPLETED:
04:45 PM
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On 6/3/2022 at 3:15,PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Miriam Cruz Rodriguez, Caregiver and explained the purpose of the visit. Maria Rivera, Administrator arrived at 3:30PM.

Upon entry, LPA's temperature was checked. LPA observed screening station that contained hand sanitizer, masks, wipes, gloves, and sign-in book. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage, and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared clients’ bathroom was measured at 110.1 degrees Fahrenheit. Fire extinguisher was last serviced on 08/16/2021.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 6/10/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLDEN AURORA HEALTHCARE INC.
FACILITY NUMBER: 079200381
VISIT DATE: 06/03/2022
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Continued from LIC809.

-LIC610D Emergency Disaster Plan

The following deficiency were observed:

-At 3:30PM, LPA observed 2 sheds in backyard that is not shown on facility sketch. 1 shed is being used for office/Staff.

The following deficiency was observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/03/2022 04:38 PM - It Cannot Be Edited


Created By: Laura Hall On 06/03/2022 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLDEN AURORA HEALTHCARE INC.
FACILITY NUMBER: 079200381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having 2 sheds not shown on facility sketch and 1 shed being used as an office/staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Administrator agreed to submit updated facility sketch and LIC200 to obtain fire clearance for both sheds to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022


LIC809 (FAS) - (06/04)
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