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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804071
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:36:37 AM


Document Has Been Signed on 01/31/2023 11:36 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: 5DATE:
01/31/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee/Administator, Edwarsdon ManaloTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 01/31/2023 to conduct a Post Licensing inspection. LPA met with Licensee/Administrator, Edwardson Manalo.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were free from obstructions. Bathrooms had necessary grab bars and nonskid mats. Water temperature was measured at 113.4 degrees F. Facility has 3 shared bedrooms. Facility had sufficient perishable and non perishable food. Fire extinguishers inspected were charged and current. Carbon monoxide and smoke detectors were present throughout the facility. Facility was a comfortable temperature. Medications were locked and secured. Toxins were locked and secured.

LPA and licensee reviewed best practices for staff and resident record keeping. LPA provided licensee with regulations 87458 (Medical Assessments), 87705 (Care of Persons with Dementia), 87506 (Resident Records), and 87463 (Reappraisals). LPA gave guidance that regulation requires annual medical assessments for resident's with dementia. Per 87463(c) licensee must arrange a meeting with resident representative anytime there is a significant change in the resident's condition or once every 12 months. Per 87458(c) the department has the authority to require the submission of an updated medical assessment. LPA and licensee reviewed form LIC 625 Appraisal/Needs and Services Plan.

Facility has obtained new admission agreements.

Exit interview conducted with licensee/administrator Edwardson Manalo. No deficiencies observed during today's inspection. A copy of this report emailed to the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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