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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200996
Report Date: 09/03/2020
Date Signed: 09/03/2020 02:52:04 PM

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 HOME RCFEFACILITY NUMBER:
079200996
ADMINISTRATOR:MENDOZA, LIWAYWAYFACILITY TYPE:
740
ADDRESS:4234 GOLDENHILL DR.TELEPHONE:
(925) 378-9906
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 0DATE:
09/03/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Liwayway and Dennis Mendoza, AdministratorTIME COMPLETED:
01:55 PM
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On 09/03/2020 at 01:05pm, Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing tele-inspection through Facetime with Liwayway and Dennis Mendoza, Administrators. The facility has an approved fire safety clearance for six (6) residents four (4) ambulatory, two (2) non-ambulatory, and a hospice waiver for two (2).

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and backyard. The facility has a total of five (4) bedrooms and three (3) bathrooms. One (1) bedroom staff/office and one (1) bathroom is only used by staff. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with grab bars and non skid mats. Passageways and hallways are free of obstruction. LPA observed locked cabinets that stores medications, toxins and sharps. Required posters are posted on the wall. Thermometer in hallway showed temperature as 77 degrees F. Emergency disaster plan dated 05/15/2020. Fire extinguisher was last serviced on 06/20/2020. First Aid kit was complete. Carbon monoxide and smoke detectors were in working condition.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Administrators and a copy of this report will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2020
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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