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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201639
Report Date: 07/27/2022
Date Signed: 07/27/2022 03:54:47 PM


Document Has Been Signed on 07/27/2022 03:54 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 SHORE CARE HOMEFACILITY NUMBER:
435201639
ADMINISTRATOR:QING GUOFACILITY TYPE:
740
ADDRESS:3800 RHODA DRIVETELEPHONE:
(408) 615-0880
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:6CENSUS: 6DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:QING GUOTIME COMPLETED:
04:05 PM
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On 07/27/2022, Licensing Program Analyst (LPA) Mandeep Kaur conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit . LPA met with Administrator Qing Guo.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, gloves, surgical masks and hand sanitizer were present at the entrance. LPA temperature was measured at the entrance by the administrator.

LPA toured the facility inside and outside. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the kitchen.
The kitchen was inspected. There was sufficient perishable food for at least 2 days and nonperishable food for at least one week.

LPA inspected the residents' restrooms. The restrooms were observed to be adequately stocked with paper towels and hand soap.
Foot operated trash containers observed in the bathrooms and in the kitchen.

No citations were issued per the California Code of Regulations Title 22.

This report was reviewed with the Administrator Qing Guo. A copy of this report and advisory notes were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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