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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804071
Report Date: 09/12/2022
Date Signed: 09/12/2022 11:51:25 AM


Document Has Been Signed on 09/12/2022 11:51 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:GOLDEN HEARTS SENIOR CARE, LLCFACILITY NUMBER:
286804071
ADMINISTRATOR:MANALO, EDWARDSONFACILITY TYPE:
740
ADDRESS:1630 ARCADIA COURTTELEPHONE:
(415) 770-4285
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 6DATE:
09/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:6TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/12/2022 to conduct a Pre-Licensing inspection. This is a change of ownership with residents in care. LPA met with applicant, Edwardson Manalo.

LPA toured building and grounds which were found to be clean and in good repair. Exits and walkways were clear and unobstructed. Exit alarms were working properly. Resident bathrooms had necessary grab bars and non-slip mats. Facility is two story building with resident bedrooms located on the first floor. There are 3 shared bedrooms. There was a sufficient supply of perishable and non-perishable food available for residents. Toxins were locked and secured. Medications were centrally stored and inaccessible to residents in care. LPA observed a sample menu and activity schedule posted. Facility had necessary licensing and LTCO postings. Extra linens and towels were available for residents. Facility has a large living room for activities and a large backyard. LPA and applicant discussed the need for new admission agreements for new license. Facility had resident and staff files available for inspection upon request. Facility has an approved fire clearance dated 04/21/2022 for 6 non-ambulatory residents.

LPA reviewed Component III with applicant.

No deficiencies observed during today's inspection. LPA will notify application unit to proceed with licensing process.

Exit interview conducted with applicant and a copy of this report printed.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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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