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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601123
Report Date: 02/06/2024
Date Signed: 02/06/2024 11:32:51 AM


Document Has Been Signed on 02/06/2024 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Arlene ArceTIME COMPLETED:
11:45 AM
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On 2/6/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Arlene Arce. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen. The indoor and outdoor passageways were free of obstruction. One resident is out for a check up. Two residents are in their room resting. Resident bedrooms were observed to have necessary furniture. All personal belongings are intact. Resident’s bathroom was equipped with grab bars and non-slip floors. Sharps and toxic materials were observed to be locked. Food supply was observed with an adequate two day perishable and seven day non-perishable food supply. While touring the facility it was observed that the room temperature was at 73 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. Emergency drills are logged and done every three months.

Three client records and three staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs.

Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested documents: LIC 500 and Certificate of Liability Insurance.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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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