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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602369
Report Date: 09/23/2022
Date Signed: 09/26/2022 08:05:09 AM


Document Has Been Signed on 09/26/2022 08:05 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 LIVING HEALTH MANAGEMENT, INC.FACILITY NUMBER:
374602369
ADMINISTRATOR:ROCIO GRANDAFACILITY TYPE:
740
ADDRESS:3223 DUKE STREETTELEPHONE:
(619) 222-1109
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY:113CENSUS: 85DATE:
09/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Manager Assitant, Andrea ZamoranoTIME COMPLETED:
04:30 PM
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Licensing Program Analyst, (LPA), Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA discussed the purpose of the visit with Manager Assitant, Andrea Zamorano.

During today’s visit, LPA briefly toured the facility, requested records, and interviewed staff and residents. The facility self reported two incidents. One incident was regarding theft involving Resident #1 (R1). The second incident was regarding Resident #2 (R2) falling and sustaining and injury.

Based on today’s inspection, there were no deficiencies cited at this time in the areas evaluated. An exit interview was conducted and a copy of this report along with Licensee's Appeal Rights (LIC 9058 01/16) were provided to

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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