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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294287
Report Date: 01/07/2021
Date Signed: 01/07/2021 04:42:40 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 HILLS CARE HOMEFACILITY NUMBER:
435294287
ADMINISTRATOR:BASILIO, CARLOFACILITY TYPE:
740
ADDRESS:2845 WESTBRANCH DRIVETELEPHONE:
(408) 528-1325
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
01/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Carlo BasilioTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Technical Assistance tele-visit today with CA Department of Public Health (CDPH) Health Facilities Evaluator Nurse (HFEN) Rebekah Bird-Wohlgemuth, RN.

At 3:06 PM, the facility with virtually toured with Administrator Carlo Basilio. Residents' bedrooms, bathrooms, living and dining room, and kitchen were inspected. Residents were observed at least 6 feet apart. Staff were observed wearing masks.

Based on facility tour and interview with Administrator, the following recommendations were provided:

1. Refrain from using table cloths that cannot be effectively sanitized after every use.

2. Facility shall use trash bins with covers throughout the facility. A trash bin with sensors or foot pedals are highly recommended to minimize the touching of surfaces.

3. Facility shall have posters on proper hand-washing techniques posted by all hand-washing stations.

4. Paper towels shall be placed on dispensers or spindles to avoid contamination of unused towels.

5. Wash basins used from residents' sponge baths shall be wiped dry and kept in each resident's room instead of stacked together while air drying.

Continued, see LIC 809-C, page 2 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HILLS CARE HOME
FACILITY NUMBER: 435294287
VISIT DATE: 01/07/2021
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6. Dilute and use cleaning solutions per manufacturer's and the Centers for Disease Control (CDC) guidelines. www.cdc.gov.

7. Screening questionnaires must be updated based on current recommendations, including an updated list of known COVID-19 symptoms. www.cdc.gov


No deficiencies were cited. Administrator to submit the following to Community Care Licensing Division (CCLD) by January 24, 2021:

1. Current LIC 500 - Personnel Schedule

2. Staff training record on Personal Protective Equipment (PPE) use including donning and doffing.

3. Update COVID-19 Mitigation Plan as outlined in Provider Information Notice (PIN) 20-48-ASC.

This report was discussed with and a copy provided to Administrator Carlo Basilio via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
LIC809 (FAS) - (06/04)
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