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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601775
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:13:57 PM


Document Has Been Signed on 01/26/2024 02:13 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
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) 856-5033
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:6CENSUS: 5DATE:
01/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Chona Simsuangco, LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit to cite for a deficiency observed during a previous visit. LPA introduced herself, was granted entry and met with Chona Simsuangco, Licensee, who arrived a short time later and with whom she discussed the purpose of the visit.

During today's visit, LPA conducted a tour of the facility, reviewed and obtained copies of facility records, and spoke with staff. LPA’s observation and information provided by licensee and staff today and during previous visit revealed that Resident 1 (R1) is bedridden and unable to reposition independently. Review of the facility's license and fire clearance revealed that the facility is cleared and licensed for non-ambulatory residents. The facility does not have an approved fire clearance to house a bedridden resident.

Based upon the foregoing, a deficiency is being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D. A civil penalty in the amount of $500 is being assessed on an LIC 421IM.

An exit interview was conducted with Chona Simsuangco at the end of the visit. Copies of this report, LIC 421IM, LIC 811, and Licensee/Appeal Rights (LIC 9058) were provided to the licensee, and her signature on this form acknowledges receipt of copies of the documents.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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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Document Has Been Signed on 01/26/2024 02:13 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: GOLDEN SAINTS HOME
FACILITY NUMBER: 374601775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2024
Section Cited
CCR
87202(a)(2)

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Fire Clearance.. . .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. . .fire department. . .or the State Fire Marshal. (2) Bedridden persons
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During LPA's visit, Licensee provided a completed LIC 200 Application and Fire Request form requesting approved bedridden clearance.
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This req't was not met as evidenced by:
Based on record review the licensee did not notify the licensing agency and obtain an approved fire clearance prior to accepting or retaining1 of 6 persons (R1), who is bedridden. This posed an immediate safety risk to persons in care.
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An immediate civil penalty in the amount of $500 is being assessed for the fire clearance violation.

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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
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