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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601775
Report Date: 04/23/2024
Date Signed: 04/23/2024 10:15:56 AM

Document Has Been Signed on 04/23/2024 10:15 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GOLDEN SAINTS HOMEFACILITY NUMBER:
374601775
ADMINISTRATOR/
DIRECTOR:		LEONARDO SIMSUANGCOFACILITY TYPE:
740
ADDRESS:2555 HOPKINS STTELEPHONE:
(619) 856-5033
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 6CENSUS: 6DATE:
04/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Celia Abuan, StaffTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced Case Management visit to observe the physical plant. LPA introduced herself, was granted entry into the facility, and met with Celia Abuan, Staff, to whom LPA disclosed the purpose of the visit.

An application for a change in bedridden status was received by Community Care Licensing on February 1, 2024. A fire clearance for five (5) non-ambulatory and one (1) bedridden was requested, and the fire clearance was approved on April 11, 2024, granting bedridden approval for Bedroom 1. The fire clearance specifies that the facility’s hallway door must remain self-closing and intact, and magnets may not hold doors open unless connected to the fire alarm.

During the visit, LPA toured the facility. No deficiencies were observed or cited during the visit. The Licensee will be notified by Community Care Licensing upon a decision of the application request.

An exit interview was conducted with Celia Abuan, and copies of this report and Licensee/Appeal Rights were provided to staff at the conclusion of the visit. Her signature below confirms receipt of the rights and a copy of this report.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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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