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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201206
Report Date: 04/12/2023
Date Signed: 04/12/2023 03:18:52 PM

Document Has Been Signed on 04/12/2023 03:18 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 AURORA HEALTHCARE CLEARBROOKFACILITY NUMBER:
079201206
ADMINISTRATOR:RIVERA, PERSEUSFACILITY TYPE:
735
ADDRESS:34 CLEARBROOK ROADTELEPHONE:
(408) 207-5172
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 0DATE:
04/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Perseus Rivera, AdministratorTIME COMPLETED:
03:25 PM
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On 04/12/2023 at 1:10PM, Licensing Program Analyst (LPA) L. Hall conducted a Component III Review, for the Pre-licensing Inspection which was conducted on this date. with Perseus Rivera , Administrator.

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

A license has not yet been granted to this facility. Licensure is subject to final review and approval by the Centralized Applications Unit. Licensee is not to accept residents until notified by Community Care Licensing that the license has been approved.

Exit interview conduct and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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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