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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200996
Report Date: 07/08/2020
Date Signed: 07/20/2020 05:46:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:GOLDEN HOME RCFEFACILITY NUMBER:
079200996
ADMINISTRATOR:MENDOZA, LIWAYWAYFACILITY TYPE:
740
ADDRESS:4234 GOLDENHILL DR.TELEPHONE:
(925) 378-9906
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: DATE:
07/08/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Liwayway Mendoza-Administrator/LLC Owner; Dennis Mendoza-Managing MemberTIME COMPLETED:
10:27 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
COMP II Participants: Liwayway Mendoza, Administrator/LLC Owner; Dennis Mendoza, Managing Member
Interview Method: Telephone interview

On 7/8/20, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Anna BarriosTELEPHONE: (916) 651-7817
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2020
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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