216803145-2-7-2023-21-AS-KMOA-CNUUPD-20230208144522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803145
Report Date: 02/07/2023
Date Signed: 02/07/2023 10:08:32 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20220916084728

FACILITY NAME:	GOLDEN HOME EXTENDED CARE, INC.		FACILITY NUMBER:	216803145
ADMINISTRATOR:	ZINGKHAI, RUFUS		FACILITY TYPE:	740
ADDRESS:	1234 LAS GALLINAS AVE		TELEPHONE:	(415) 297-4342
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	28	CENSUS: 19	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Staff Member, Giov Alipio, and Administrator, Rufus Zingkhai		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for the Complaint Investigation regarding the above allegation and met with Staff Member, Giov Alipio. Administrator, Rugus Zingkhai, arrived later during visit at approximately 9:50AM.

During the course of the investigation, LPA Felias reviewed and requested documents, made observations at the facility, and conducted interviews. Per information provided to LPA, Resident 1 (R1) reported that facility staff slapped them, pushed them, and pulled their hair. R1 reported to have no recollection of when the personal rights violations occurred. Staff interviews conducted revealed no knowledge of clients being slapped, pushed down, or having their hair pulled. Resident interviews conducted stated that staff treat them well, are attentive, and assist them with their care needs. Interview with R1’s case manager stated that R1 does not have a history of false accusations.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220916084728

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN HOME EXTENDED CARE, INC.	FACILITY NUMBER: 216803145
	VISIT DATE: 02/07/2023

NARRATIVE

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Continued from LIC9099

Review of Records dated 10/16/2019 and 10/17/2019 indicated that Resident has a history of false accusations. Based on interviews conducted and record review, the LPA is unable to determine if there was a Personal Rights violation, therefore this allegation is Unsubstantiated.

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during Visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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