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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200974
Report Date: 06/02/2023
Date Signed: 06/02/2023 02:00:51 PM

Document Has Been Signed on 06/02/2023 02:00 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:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Kathleen Tano, Direct Support ProfessionalTIME COMPLETED:
02:10 PM
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On 6/1/2023 at 12:05PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Kathleen Tano, Direct Support Professional, (DSP), and explained the purpose of the visit. Administrator, Maria Rivera, arrived at 12:20PM. LPA toured the facility with Maria Rivera. The administrator currently holds a certificate (#6027051735) that expires on 6/23/2023. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and two (2 ) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 115.0 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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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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 ENTRADA
FACILITY NUMBER: 079200974
VISIT DATE: 06/02/2023
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 3/29/2023. Fire drill last conducted 5/16/2023. First aid kit was observed to be complete.

Three (3) staff records were reviewed, and all staff have first aid and CPR. All three (3) clients records reviewed, current, and complete. LPA also reviewed P & I.

The following forms to be updated and submitted to CCLD by 6/9/2023:
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC 610D Emergency disaster plan
  • Liability insurance.
  • LIC500 (Personnel Record)
  • Client Roster

No deficiencies cited during inspection.

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

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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