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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294074
Report Date: 09/23/2021
Date Signed: 09/23/2021 02:51:14 PM

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 FACILITIES & SERVICESFACILITY NUMBER:
435294074
ADMINISTRATOR:MABUTAS, FELYFACILITY TYPE:
740
ADDRESS:3884 WIVEN PLACE WAYTELEPHONE:
(408) 440-4725
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 5DATE:
09/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Fely MabutasTIME COMPLETED:
02:30 PM
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Licensing Program Analyst, Steve Nguyen, conducted an unannounced annual inspection with Administrator (AD), Fely Mabutas

LPA toured facility inside and out. LPA observed: Covid signs are present and in conspicuous vantage points, are exits are free of obstructions, emergency contact for residents were up to date, facility screening protocols will be enforce and staff will be retrained by AD, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use, all beds are at least 6 feet apart and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Administrator, Fely Mabutas, for review and a copy was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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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