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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803145
Report Date: 03/18/2024
Date Signed: 03/18/2024 11:01:56 AM


Document Has Been Signed on 03/18/2024 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
03/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator, Rufus ZingkhaiTIME COMPLETED:
11:10 AM
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At approximately 9:40AM, Licensing Program Analysts (LPAs) Felias and Florio arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Rufus Zingkhai. The purpose of today's visit is to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 02/26/2024. Report stated that on 02/21/2024, Facility observed an anal fissure on Resident 1 (R1). Facility contacted 911 and Home Health Nurse and R1 was transported to the hospital for evaluation. Facility made all appropriate notifications per regulation.

Incident Report 2/SOC-341: CCL received an incident report and SOC-341 on 03/12/2024. Reports stated that on 03/11/2024, R1's Responsible Party reported to staff that R1 could have had forced trauma injuries to their rectal area. Facility made all appropriate notifications per regulation.

LPAs requested and reviewed documents.

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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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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