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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201163
Report Date: 04/21/2022
Date Signed: 04/21/2022 12:55:18 PM


Document Has Been Signed on 04/21/2022 12:55 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:GOLDEN HILL HOMES, INC.FACILITY NUMBER:
079201163
ADMINISTRATOR:ANSARI, FATHMAFACILITY TYPE:
740
ADDRESS:9474 ALCOSTA BLVDTELEPHONE:
(949) 278-8332
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: DATE:
04/21/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Facility Type: RCFE
Application Type: CHOW
Capacity: 6
COMP II Participants: Ansari, Fathma, Corporate Board Member/ Administrator
Interview Method: Telephone interview
TIME COMPLETED:
12:30 PM
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On 04/21/2022 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
Pre-licensing readiness
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Katie KeithTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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