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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 01:54:12 PM


Document Has Been Signed on 05/06/2022 01:54 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:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Fathma Ansari, AdministratorTIME COMPLETED:
02:05 PM
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On 5/6/2022 at 10:00 AM, Licensing Program Analyst (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct a Pre-licensing Inspection. Upon arrival, LPAs were greeted by Care Staff, Rodora Suzon. Administrator, Fathma Ansar later arrived at 10:24 AM. The facility's fire clearance was approved for all six residents may be non-ambulatory.

LPAs toured facility with Administrator and Care Staff including but not limited to 6 residents bedrooms, 2 staff rooms, 4 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 71 degrees F and hot water temperature was maintained at 107.6 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 11/1/2021.

During record review, LPAs reviewed a sample of 2 residents and 3 staff records. 2 of 2 residents and 3 of 3 staff have current records maintained.

The following were cited and corrected from a Case Management for existing license (#075601511):
  • At 10:30 AM, LPAs observed two knives being stored inside dishwasher accessible to residents. Deficiency cleared during visit. Staff removed both knives and locked it away.
  • At 10:33 AM, LPAs observed laundry detergent unlocked placed above laundry machines. Deficiency cleared during visit. Staff removed detergents from shelf and locked it away inside a cabinet.


REPORT CONTINUES ON 809C
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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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 HILL HOMES, INC.
FACILITY NUMBER: 079201163
VISIT DATE: 05/06/2022
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LPAs 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 and a copy of this 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
LIC809 (FAS) - (06/04)
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