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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708303
Report Date: 08/05/2021
Date Signed: 08/05/2021 04:03:36 PM

Document Has Been Signed on 08/05/2021 04:03 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
CCLD Regional Office, 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: 4DATE:
08/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Alegria SorianoTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) David Marrufo conducted an unannounced Case Management visit and met with Alegria Soriano.

During visit, LPAs observe there to be three sharp scissors unsecured in the kitchen area while there is a resident with dementia in care. LPAs also observed that the facility did not have a Roster of Residents. LPAs reviewed facility personnel records and observed that Staff S1 and co-licensees/administrators Mars and Alegria Soriano did not have current CPR/First Aid training.


Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information.

This report was reviewed with Alegria Soriano and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2021
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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Document Has Been Signed on 08/05/2021 04:03 PM - It Cannot Be Edited


Created By: David Marrufo On 08/05/2021 at 03:37 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: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2021
Section Cited
CCR
87705(f)(1)

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(f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Licensee agrees to secure sharp objects, including the three scissors by POC date.

***During visit, Licensee secured the three scissors. POC Cleared
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This requirement was not met as evidenced by: Licensee did not secure three sharp scissors while caring for a resident with dementia, which poses an immediate safety risk to residents in care.
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during visit.***
Type B
08/12/2021
Section Cited
CCR87508(a)

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(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information:
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Licensee agrees to complete a register of residents at the facility and submit a copy of the register to CCL by POC date.
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This requirement was not met as evidenced by: Licensee did not maintain a register of residents, which poses a potential safety risk to residents 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:Jackie Jin
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2021 04:03 PM - It Cannot Be Edited


Created By: David Marrufo On 08/05/2021 at 03:44 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: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2021
Section Cited
CCR
87411(c)(1)

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(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement was not met as evidenced by: Licensee did not
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Licensee agrees to have both co-licensees/administrators and staff S1 obtain current first aid training and submit copies of their certificates to CCL by POC date.
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ensure that both co-licensees/administrators and staff S1 had current first aid training certificates, which poses a potential safety risk to residents 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:Jackie Jin
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021


LIC809 (FAS) - (06/04)
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