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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201163
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:55:22 PM


Document Has Been Signed on 05/06/2022 01:55 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 5DATE:
05/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Fathma Ansari, AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
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On 5/6/2022 starting at 12:30 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen conducted a face to face Component III presentation. LPAs conducted Component III with Administrator, Fathma Ansari.

LPAs presented Component III power point and discussed the regulations embodied in the power point. LPAs observed participant gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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