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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601775
Report Date: 01/11/2024
Date Signed: 01/11/2024 01:23:26 PM


Document Has Been Signed on 01/11/2024 01:23 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:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Chona Simsuangco, LicenseeTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced required annual inspection. LPA introduced herself and was granted entry into the facility by Lorilee Luna, Staff, to whom LPA disclosed the purpose of the visit. The licensees, Leonardo and Chona Simsuangco, arrived a short time later.

According to the facility’s license, the facility has a maximum capacity of six (6) residents, all of whom may be non-ambulatory. During today’s inspection, there were a total of five (5) residents residing in the home.

LPA, accompanied by facility staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors and equipment inspected were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at sink accessible to clients measured at 113.7 degrees Fahrenheit.

Refrigerators and freezers were operational. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in a locked closet.


No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, and facility telephone were in working order. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff. The interviews did not raise any licensing concerns. LPA reviewed records/files. Staff are current on training requirements. Staff files contained required documents. Confidential records were stored in locked cabinets.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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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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
VISIT DATE: 01/11/2024
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No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Chona Simsuangco, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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