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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200974
Report Date: 05/10/2023
Date Signed: 05/10/2023 01:35:28 PM

Document Has Been Signed on 05/10/2023 01:35 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 ENTRADAFACILITY NUMBER:
079200974
ADMINISTRATOR:RIVERA, MARIA THERESAFACILITY TYPE:
735
ADDRESS:2729 ENTRADA CIRCLETELEPHONE:
(408) 207-5172
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 3DATE:
05/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Maria Theresa Rivera, AdministratorTIME COMPLETED:
01:45 PM
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On 5/10/2023 at 12:55PM Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit to follow-up on a death report received by Community Care licensing on 5/1/2023. LPA met with Administrator, Maria Rivera and explained the purpose of the visit.

R1 passed away on 5/1/2023 with an unknown cause of death. During today's visit LPA requested additional information pertaining to Client 1 (C1's) death to be submitted by the close of business today:
  • Physician's report (LIC602)
  • Appraisal needs and services plan
  • Admission agreement
  • Identification and emergency contact
  • Client roster
  • Staff roster
  • Individual Program Plan (IPP)

LPA was informed by Administrator that family will provide R1's death certificate, once available and will provide CCL a copy.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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