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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602679
Report Date: 05/29/2024
Date Signed: 05/30/2024 03:33:22 PM


Document Has Been Signed on 05/30/2024 03:33 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 HEARTS HOME CAREFACILITY NUMBER:
374602679
ADMINISTRATOR:MACAPAGAL, ESTRELLAFACILITY TYPE:
740
ADDRESS:10197 SPRING MANOR COURTTELEPHONE:
(858) 433-7338
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff, Felix AgpawaTIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Felix Agpawa.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers 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 resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 114 F.

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, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas.


No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed multiple staff and residents. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Staff, Felix Agpawa to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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