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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607756
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:17:40 PM


Document Has Been Signed on 07/24/2023 01:17 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:GOLDEN ROAD ASSISTED LIVINGFACILITY NUMBER:
197607756
ADMINISTRATOR:ANA SANTOSFACILITY TYPE:
740
ADDRESS:438 N. CALIFORNIA STREETTELEPHONE:
(626) 287-6792
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:6CENSUS: 3DATE:
07/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ana Santos TIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Galarza conducted a case management visit and met with Licensee Ana Santos. The scope of today’s visit is for the purpose of a capacity increase from four (4) beds to six (6) beds.The facility is licensed to serve elderly residents over the age of 59 years. The fire safety inspection clearance was granted by City of San Gabriel Fire Department Inspector S.Heckunyan effective 6/17/2023.


It consists of 5 bedrooms; 4 for residents [3 private & 1 shared) and 1 staff bedroom for licensee, 3 bathrooms, living room, dining room, kitchen, outdoor covered patio area, laundry room, and a 3 car detached garage in the rear of the property presently being used as storage area.

The capacity increase is granted for six (6) residents. The facility has a Dementia waiver in place and a hospice waiver for two (2) residents.

A new license with the capacity change will be mailed to Licensee. Licensee was informed that the old license is now void.



An exit interview was conducted with Licensee Ana Santos. A copy of the report was issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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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