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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601123
Report Date: 09/30/2022
Date Signed: 09/30/2022 02:06:03 PM


Document Has Been Signed on 09/30/2022 02:06 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:
385601123
ADMINISTRATOR:ARCE, ARLENE MAGTIBAYFACILITY TYPE:
740
ADDRESS:166 FOOTE AVENUETELEPHONE:
(415) 587-2507
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:6CENSUS: 3DATE:
09/30/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Arlene ArceTIME COMPLETED:
02:30 PM
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Applicant Rochelle Magtibay Pacia has applied for RCFE licensure for 6 ambulatory elderly clients over age 59 in 3 rooms. Fire clearance has been approved. Facility is currently licensed and operating under the same name #385600007, which is reflected on application (LIC200). There are 3 residents present.
LPA Jeung toured facility and grounds of this two level facility. Clients reside on upper level, where there are 3 shared bedrooms, living room, full bathroom and dine-in kitchen. Live-in staff reside on the ground level, which includes kitchen and bathroom. Clothes washer and dryer are located in garage.
COVID signs are prominently posted, including handwashing reminder sign at bathroom sink. The backyard is level and fenced, and a detached storage shed is used by live-in staff. Medications and toxins are secured in separate locked cabinets in kitchen. Food preparation and service items are present, as well as perishable and non-perishable fruits, vegetables and protein. Supplies of bed and bath linens and hygiene products are observed.
The following items are observed and must be addressed prior to licensure:

1. Hot water temperature tested at 138 degrees F in client bathroom (Section 87307 Maintenance/Operation)
2. Lamps are not installed in each client bedroom. (Section 87307 Personal Accommodations/Services)
3. Clients' beds are not fitted with mattress pads and top sheets (Section 87307)
4. Nightstand is not installed next to bed in room of client #1. Instead, there is a large empty dresser between the 2 beds. (Section 87307)
5. Facility sketch does not clearly delineate the floor plan and does not include evacuation assembly location. (Section 87208 Plan of Operation)
6. The Emergency Disaster Plan (LIC610E, rev. 3/19) must be checked for accuracy and resubmitted to CCLD, and include provision of emergency power (page 4) and location of fire extinguishers on page 3. Administrator and staff must be familiar with the Plan and knowledgeable about utility shut-off locations. (Health and Safety Code 1565)
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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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: 385601123
VISIT DATE: 09/30/2022
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7. There is no emergency signal system for clients to summon staff--who reside on ground level--in the event of an emergency. (Section 87303 Maintenance and Operation)
8. Proof of liability insurance is not on file. (Health/Safety Code 1569.605)
9. Admission agreement of notice of availability of admission agreement is not posted. (Section 87507 Admission Agreements)
10. There is no client roster available--LIC9020. (Section 87508 Register of Residents)
11. Personal Rights are not posted, including non-discrimination notice and complaint information. (Section 87468 Personal Rights)
12. CCLD Complaint poster (PUB475) is not posted. (Section 87468)
13. There is no posting of Rights of Resident Councils. (Health/Safety Code 1569.157)
14. There is no posting of information on family councils. (Health/Safety Code 1569.158)

Items referenced above to be addressed, and proof to be provided to LPA prior to licensure.

Facility phone number is 415/587-2507.

RCFE administrator certificate for Ms. Arce was sent to Administrator Certification Unit in Sacramento with proof of 40 hours of training, but renewal certificate has not yet been received.



Component III orientation to be reviewed during follow-up visit.
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
LIC809 (FAS) - (06/04)
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