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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201210
Report Date: 08/30/2024
Date Signed: 08/30/2024 11:58:49 AM

Document Has Been Signed on 08/30/2024 11:58 AM - 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/
DIRECTOR:		GONZALEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:4541 PAMPAS CIRCLETELEPHONE:
(925) 628-9912
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 4CENSUS: 4DATE:
08/30/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Lady Gonzalez, StaffTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 08/30/24 at 11:30 AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check to discuss the denial of a 3 day eviction.

During the health and safety check, LPA observed a total of 3 staff members and 4 clients at the facility. LPA toured facility with staff, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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