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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004502
Report Date: 07/02/2021
Date Signed: 07/02/2021 10:17:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN PINE GUEST HOMEFACILITY NUMBER:
397004502
ADMINISTRATOR:MARIVIC TEANO-CHUAFACILITY TYPE:
740
ADDRESS:314 WEST PINE STREETTELEPHONE:
(209) 334-6441
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:15CENSUS: 15DATE:
07/02/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angelia Yapo - Direct CareTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Plan of Correction Visit. LPA met with Direct Care (DC) to discuss the POC's. DC showed LPA the repaired hole in walls and replaced floor tiles. In addition, DCshowed LPA the removed broken fan in ceiling and replaced with a light fixture. Now there is a floor fan to help keep client's room cool.

LPA determined DC repaired holes in wall, replaced floor tiles, and removed broken fan; so no further action required.

No deficiencies cited on today's visit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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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