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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201210
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:08:41 PM

Document Has Been Signed on 10/19/2022 12:08 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 STATE CARE HOME, INCFACILITY NUMBER:
079201210
ADMINISTRATOR:GONZALEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:4541 PAMPAS CIRCLETELEPHONE:
(925) 628-9912
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 4CENSUS: 0DATE:
10/19/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michelle Gonzalez, Administrator/Licensee
Jonathan Sanchez, Licensee/Applicant		TIME COMPLETED:
11:00 AM
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On 10/19/2022 at 9:30AM, Licensing Program Analyst (LPA) G. Luk conducted a Pre-licensing Inspection. LPA met with Licensee/Administrator, Michelle Gonzalez and Licensee, Jonathan Sanchez.

The facility's fire clearance was approved for 4 ambulatory clients.



LPA toured facility including but not limited to client's bedrooms, bathrooms, living room, kitchen, garage, and outdoor area. Client's rooms were fully furnished and clean. Hot water was measured at 112.4 degrees F in the kitchen sink. LPA observed lighting in all rooms. LPA observed facility had some non-perishable and perishable food supply. Licensee will purchase additional food supplies once facility is licensed. Smoke and carbon monoxide detectors were observed in operating conditions. Facility has a working phone on premises. First aid kit was complete. Emergency disaster plan was complete. Fire extinguisher was observed to be full and last serviced on 9/1/2022. Indoor and outdoor passageways are free of obstruction.

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

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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