<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601775
Report Date: 11/29/2021
Date Signed: 11/29/2021 05:08:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GOLDEN SAINTS HOMEFACILITY NUMBER:
374601775
ADMINISTRATOR:LEONARDO SIMSUANGCOFACILITY TYPE:
740
ADDRESS:2555 HOPKINS STTELEPHONE:
(619) 434-3027
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:6CENSUS: 6DATE:
11/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee/Administrator, Chona SimsuangcoTIME COMPLETED:
12:10 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
Licensing Program Analyst (LPA) Lizzette Tellez conducted an unannounced case-management visit. LPA was met by Caregiver, Lilia Deona, and was granted entry into the facility. LPA met with Licensee/Administrator, Chona Simsuangco, and discussed the purpose of the visit.

This visit was initiated due to the death of Client #1 (C1). Ms. Simsuangco was provided with Confidential Names Form, in order to identify C1. It was reported to Community Care Licensing (CCL), that C1 passed away on 10/13/21.

During today's visit, LPA toured the facility, conducted interviews, and reviewed C1's records. A copy of C1's death certificate was requested to be provided by Ms. Simsuangco once received. No immediate health and/or safety concerns were observed during the visit.

No deficiencies were cited during today's visit. An exit interview was conducted with Ms. Simsuangco, and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to them via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1