216803145-9-19-2023-21-AS-DTOA-CVTUWE-20230919155638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803145
Report Date: 09/19/2023
Date Signed: 09/19/2023 03:56:45 PM

Document Has Been Signed on 09/19/2023 03:56 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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: 17	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:59 PM
MET WITH:	Rufus Zingkhai, Administrator		TIME COMPLETED:	04:15 PM

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	9/19/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Administrator, Rufus Zingkhai. The facility is licensed for all non-ambulatory rooms and a hospice waiver for six. The facility currently provides care for 17 residents, three of which is receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility exits were properly equipped with auditory alarms for residents with dementia, tested and found to be in working order. Residents are also equipped with pendant systems that signal to the front hallway; audible from the kitchen, common area and medication office. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 9/11/2023. Both smoke detectors and carbon monoxide detectors throughout the facility were, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food properly labeled. Facility also follows appropriate dietary protocol for residents in care with dietary list posted in the kitchen area. Toxins, sharps and other items that could pose threat if readily available to residents were kept secured in the kitchen, laundry room and storage closets. Residents were observed engaging in discussion with staff and one another, listening to live music in the living area or resting in their bedrooms. There are also two large outdoor deck locations available for resident use. Residents appear to have a positive relationship with staff based on LPA observations. Staff were observed continuously assisting and supervising residents and conducting room checks during LPA's inspection. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/19/2023

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There was a supply of hygiene products, continence products, paper products and clean linens available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications are stored in a designated medication cart located in the staff office and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Upon count LPA found all administered medication to be in order.

A sample file review for staff was conducted and LPA found all staff to have sufficient 1st Aid & CPR certification and annual training on file. LPA also conducted a file review for all residents and found all resident records including physician's report and needs & service plans updated. Upon review, LPA found that resident (R1) received a physical exam and determined to be bedridden for "15" days. Facility currently does not have a clearance to admit residents with bedridden status. Administrator agrees to contact R1's PCP and request for an updated physician's report to determine R1's current ambulation status. Technical Violation issued.

Administrator, Rufus Zingkhahi's Administrator Certificate 6053315740 is currently pending. LPA reviewed current DSS pending list and confirmed the department has received as of 5/12/2023 and are processing the renewal documents.

LPA requested the following documents be sent to CCL by COB 10/19/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property

No deficiencies cited during today's visit

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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