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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 12:09:34 PM

Document Has Been Signed on 10/19/2022 12:09 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:Case Management - OtherANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Michelle Gonzalez, Administrator/Licensee
Jonathan Sanchez, Licensee		TIME COMPLETED:
12:22 PM
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On 10/19/2022 at 11:00AM, Licensing Program Analyst (LPA) G. Luk conducted a face to face Component III presentation. LPA met with Licensee/Administrator, Michelle Gonzalez and Licensee, Jonathan Sanchez.

LPA presented Component III power point and discussed the regulations embodied in the presentation. LPA observed Licensees and Administrator gained knowledge about running and maintaining the facility in accordance with Title 22 regulations.

LPA concluded Component III.

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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