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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601123
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:17:56 PM


Document Has Been Signed on 11/04/2022 04:17 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:
11/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Arlene ArceTIME COMPLETED:
04:30 PM
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In response to submission of notice that all items noted on Facility Evaluation Report of 9/30/22 have been addressed to meet physical plant requirements of California Code of Regulations, Title 22 for licensure of 6 elderly residents, LPA Jeung observed and verified the following items:

1. Clients' beds are fitted with mattress pads and top sheets (Section 87307)
2. Nightstand is installed next to bed in room of client #1. Large dresser that was between the 2 beds has been relocated against a wall.(Section 87307)
3. Facility sketch delineates the floor plan and includes evacuation assembly location and address. (Section 87208 Plan of Operation)
4. The Emergency Disaster Plan (LIC610E, rev. 3/19) has been revised and resubmitted to CCLD, and addresses that provision of emergency power is not needed for medical devices that depend upon electricity (page 6) and includes 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)
5. Admission agreement is posted. (Section 87507 Admission Agreements)
6. Client roster (LIC9020) was submitted to CCLD. (Section 87508 Register of Residents)
7. Personal Rights are posted, including non-discrimination notice and complaint information. (Section 87468 Personal Rights)
8. CCLD Complaint poster (PUB475) is posted. (Section 87468)
9. Rights of Resident Councils is posted. (Health/Safety Code 1569.157)
10. Information on family councils is posted. (Health/Safety Code 1569.158)
11. Lamps are installed in each client bedroom. (Section 87307 Personal Accommodations/Services)

Continued on following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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: 11/04/2022
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The following observations are made, and must be addressed prior to licensure:

1. Hot water temperature tested at 128 degrees F in client bathroom (Section 87307 Maintenance/Operation)
2. Emergency signal system for clients to summon staff--who reside on ground level--in the event of an emergency is not functioning properly.. (Section 87303 Maintenance and Operation)
3. Proof of liability insurance is not on file. (Health/Safety Code 1569.605)

Administrator to notify LPA upon completion and verification of above referenced items.


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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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