216803145-9-23-2024-21-AS-CFES-D9DTZQ-20240923151043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803145
Report Date: 09/23/2024
Date Signed: 09/23/2024 03:10:51 PM

Document Has Been Signed on 09/23/2024 03:10 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
SANTA ROSA RO, 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: 16	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Staff Member/Designated Representative, Angel Socito, and Administrator, Rufus Zingkhai		TIME COMPLETED:	03:15 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	At approximately 1:40PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Angel Socito. Administrator, Rufus Zingkhai arrived during visit at approximately 2:00PM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 30 non-ambulatory residents and has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 16 Residents in care and 3 staff members on-site. At approximately 1:50PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:55PM, LPA conducted a walk-though of the facility with Staff Member. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 15 Resident bedrooms, 8 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for a sample size of 4 sinks were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's last emergency/disaster drill was conducted September 2024. Facility's fire extinguishers were last inspected August 2024. Facility has a hard wired fire alarm and sprinkler system that is directly connected to the local Fire Department. Facility's smoke detectors and sprinkler system were last inspected August 2024. Facility's carbon monoxide detectors were tested and operational. Continued on LIC809C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
	VISIT DATE: 09/23/2024

NARRATIVE

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Continued from LIC809

During walkthrough, LPA was informed that Facility currently has 1 resident with bedridden status. Facility currently does not have a clearance to admit residents with bedridden status. Licensee to submit a new LIC200 and updated facility sketch to Community Care Licensing (CCL) so a new fire clearance can be requested (deficiency cited, see LIC809D, regulation 87202(a)(2)). Licensee understands that if a new fire clearance is not granted by the local Fire Department, the resident will have to be relocated due to requiring a higher level of care.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2024 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, Licensee did not comply with the section cited above. LPA observed that there is currently 1 bedridden resident residing at the facility which is out of compliance with facility license and approved fire clearance. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2024
	Plan of Correction
1 2 3 4	Licensee to submit a new LIC200 and updated facility sketch for a new fire clearance request to Community Care Licensing (CCL) by POC due date of 10/03/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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