<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803145
Report Date: 07/22/2021
Date Signed: 07/22/2021 11:42:45 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GOLDEN HOME EXTENDED CARE, INC.FACILITY NUMBER:
216803145
ADMINISTRATOR:ZINGKHAI, RUFUSFACILITY TYPE:
740
ADDRESS:1234 LAS GALLINAS AVETELEPHONE:
(415) 297-4342
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:28CENSUS: 16DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Med tech, Melvin Acala
Administrator, Rufus Zingkhai
TIME COMPLETED:
11:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Golden Home Extended Care, Inc. for the purpose of conducting a Required-1 year inspection. LPA was greeted at the double doors by Med tech, Melvin Acala. Med tech granted access into the facility. Administrator arrived at 10:47 AM and greeted LPA.

LPA began a tour with the Administrator at 10:47 AM. Building and grounds were found to be clean and a comfortable temperature of 75 degrees at the time of the Required-1 year inspection. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secured in a locked laundry room and not accessible to clients. There is a sufficient supply of hygiene products and linens on hand for client use. Water temperature measured within regulation between 105 and 120 degrees F. There were 3 fire extinguishers which were last charged August 2020. Smoke detectors were tested and found to be in working order. Carbon monoxide detectors were located in client’s hallways and were tested and found to be in working order. Disaster/Fire drills are conducted quarterly with the last drill conducted May 2021. Medication is centrally stored in a staff office locked safely in medication drawers.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage office located in the staff room. Staff have had all PPE training required on file and still working towards acquiring N-95 fit testing.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Rufus Zingkhai.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1