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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294261
Report Date: 10/22/2020
Date Signed: 10/22/2020 09:59:32 AM

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 HERITAGE SENIOR LIVINGFACILITY NUMBER:
435294261
ADMINISTRATOR:MAR, DANNYFACILITY TYPE:
740
ADDRESS:1275 N. FOURTH STREETTELEPHONE:
(408) 392-0752
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:68CENSUS: 0DATE:
10/22/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Danny MarTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an announced Case Management visit over Zoom and met with Administrator Danny Mar and Deborah Mar. The visit was conducted over Zoom due to the ongoing COVID-19 Shelter-in-Place order throughout the county and state. The purpose of the visit was to conduct a tour of the facility to ensure that no residents were residing in the facility in order to move forward with the facility closure process.

During visit, LPA Marrufo was given a virtual tour of all 51 apartments and did not observe any residents. LPA Marrufo requested that Administrator Mar submit his copy of his Administrator's certificate to CCL.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed Administrator Danny Mar. A copy of the report will be sent to Administrator Mar for him to sign and return to CCL.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
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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