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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600007
Report Date: 09/30/2022
Date Signed: 09/30/2022 02:14:39 PM


Document Has Been Signed on 09/30/2022 02:14 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:GOLDEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600007
ADMINISTRATOR:MAGTIBAY, ANTONINA M.FACILITY TYPE:
740
ADDRESS:166 FOOTE AVENUETELEPHONE:
(415) 587-2507
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:6CENSUS: 3DATE:
09/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Arlene ArceTIME COMPLETED:
02:30 PM
NARRATIVE
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During pre-licensing visit, LPA Jeung observed deficiencies of the CA Code of REgulations, Title 22, which are cited on a following page.

This facility is being closed and will be licensed under different ownership. See separate Facility Evaluation Report for #385601123 for pre-licensing inspection. Administrator is instructed to submit a letter of facility closure to residents and/or their responsible parties, and CCLD within TEN days.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
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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Document Has Been Signed on 09/30/2022 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: GOLDEN RESIDENTIAL CARE HOME
FACILITY NUMBER: 385600007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2022
Section Cited

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MAINTENANCE AND OPERATION
Faucets used by residents for personal care such as ...shall deliver hot water... shall be maintained ...to attain a temperature of not less than 105 degree F and not more than 120 degree F.
This requirement is not met, as hot water temperature is tested at 138 degrees F in
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client bathroom. Licensee failed to ensure that hot water temperature is maintained between 105 and 120 degrees, which poses an immediate health and safety risk for clients in care.
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Type A
10/03/2022
Section Cited

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MAINTENANCE AND OPERATION
Facilities shall have signal systems which shall meet the following criteria:
All facilities...having separate floors or buildings shall have a signal system which shall operate from each resident's living unit, transmit a visual and/or auditory signal to a central staffed location or produce an
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auditory signal at the living unit loud enough to summon staff, iddentify the specific resident living unit.
This requirement is not met, as there is no emergency signal system for clients to summon staff--who reside on ground level--in the event of an emergency. Licensee failed to ensure that emergency signal system is in place, which poses an immediate health & safety risk.
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2