385600007-11-30-2021-14-AS-CFGS-C99MKF-20211130084040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600007
Report Date: 11/29/2021
Date Signed: 11/30/2021 08:40:52 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME:	GOLDEN RESIDENTIAL CARE HOME		FACILITY NUMBER:	385600007
ADMINISTRATOR:	MAGTIBAY, ANTONINA M.		FACILITY TYPE:	740
ADDRESS:	166 FOOTE AVENUE		TELEPHONE:	(415) 587-2507
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94112
CAPACITY:	6	CENSUS: 3	DATE:	11/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Rosalinda Guevarra - staff		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Rosalinda Guevarra. Licensee/Administrator Antonina Magtibay has passed away and a new pending application is in place. Rochelle Magtibay is the acting administrator at this time and was contacted by staff on the phone. Acting administrator Rochelle M. wasn't able to be present at the facility. Facility has 3 residents that were present at the facility. LPA arrived at the facility and didn't have her temperature checked and logged into visitor’s binder. Per staff RG thermometer is not working and temperatures for staff and residents have not been checked lately. During facility tour on 11/29/2021 with staff Rosalinda Guevarra facility was found to be sparkling clean and at a comfortable temperature with all exits free from obstruction. Resident's bedrooms; common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detector were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the kitchen by the stove. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Hot water temperature measured 138.9 degrees F failing out of Title 22 acceptable regulations of 105 to 120 degrees F (LIC 809-D) Infection Control: Facility has submitted a mitigation program plan that hasn't been approved and there wasn't a copy available at the facility. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has only surgical masks available as PPE in the facility entrance and living room. There are no other PPE items available.Facility has not hired or admitted anyone new since COVID-19. Residents’ medications are stored and locked in the kitchen area. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GOLDEN RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600007
	VISIT DATE: 11/29/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff placed a mask on during this visit.

In addition, facility has a designated area for visitors which are being allowed. Residents have also available telephone calls when contacting family members and others. Facility wasn't able to provide LPA proof of PPE training required and are working towards obtaining N-95 fit testing.

LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Department is requesting Licensee to update and submit the following documents to CCLD by 12/06/2021:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 9120 Clients/Residents Roster
LIC 610 Emergency Preparedness
LIC 610 ES Supplemental Emergency Preparedness
Copy of Administrator Certificate
Copy of Liability Insurance
Copy of Fire Drill Log for the last 12 months

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

LIC809 (FAS) - (06/04)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GOLDEN RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 resident's bathroom faucet which poses an immediate health, safety or personal rights risk to persons in care. LPA toured the facility and checked hot water temperature for only resident's bathroom which measured 138.9 degrees F.
	POC Due Date: 11/30/2021
	Plan of Correction
1 2 3 4	Licensee to ensure that all bathroom faucets for residents will have hot water measuring between 105.0 and 120 degrees F as required per Title 22 Regulations. Licensee to adjust hot water temperature and submit self certification by POC due date of 11/30/2021. In addition, facility to submit a 7 day hot water temperature log by 11/7/2021 in order to clear this citation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

LIC809 (FAS) - (06/04)

Page: 3 of 7