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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708303
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:59:52 PM

Document Has Been Signed on 12/08/2022 03:59 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:GOLDEN AGERS HOMEFACILITY NUMBER:
430708303
ADMINISTRATOR:SORIANO, ALEGRIAFACILITY TYPE:
740
ADDRESS:1887 KILCHOAN WAYTELEPHONE:
(408) 286-6277
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 0DATE:
12/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Alegria SorianoTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit based on violations that occurred during a complaint investigation. LPA met with Licensee, Alegria Soriano and Administrator, Mars Soriano.

In December 2021, resident (R1) requested the Licensee to purchase a supplement. Licensee did not provide the resident with a receipt and change after purchase. On 07/29/2022, the Licensee provided R1 with the change after R1’s frequent reminders. R1 was still not provided the receipt.

During record review, 3 out of 3 resident’s admission agreement did not include the acknowledgment by a signature or initial of being advised of the residents personal rights.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Licensee, Alegria Soriano and Administrator, Mars Soriano and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/08/2022 03:59 PM - It Cannot Be Edited


Created By: Christine Dolores On 12/08/2022 at 03:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: GOLDEN AGERS HOME
FACILITY NUMBER: 430708303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2022
Section Cited
CCR
87217(b)

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(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by:
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Licensee will review the section cited and submit a statement of understanding to LPA Dolores via email by POC due date.
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Based on interview, the licensee did not ensure to provide R1 with the receipt and change after a requested purchase within an adequate timeframe, which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
12/09/2022
Section Cited
CCR87507(c)

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(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
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Licensee will review the section cited and submit a statement of understanding to LPA Dolores via email by POC due date.
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Based on record review, 3 out of 3 resident’s admission agreement did not include the acknowledgment by a signature or initial of being advised of the residents personal rights which poses an potential health, safety, and personal rights risk to persons in care.
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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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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