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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803145
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:22:01 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:
12/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 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.

During this Case Management-Incident, LPA interviewed S2, Administrator, Client #1 and obtained a facility sketch. LPA reviewed the following files:

-Client file
-Staff files for S1 and S2
-Disciplinary Records (including write ups, etc)

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: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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