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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803145
Report Date: 11/19/2021
Date Signed: 11/19/2021 02:42:57 PM

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: 17DATE:
11/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator, Rufus ZingkhaiTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Golden Home Extended Care, Inc for the purpose of conducting a Case Management-Incident inspection. LPA was greeted at the door by Administrator, Rufus Zingkhai and was granted access into the facility.

LPA interviewed Administrator, R1 and R2 regarding the Special Incident Report. LPA will interview night staff at a later date and time. LPA requested the following documents:

-LIC 602
-Care Plan
-LIC 500
-Contact information for night staff
-Staff training

Exit interview was conducted and a copy of this report was emailed to the Administrator, Rufus Zingkhai.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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