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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294287
Report Date: 04/20/2021
Date Signed: 04/20/2021 03:38:09 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:
04/20/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Carlo BasilioTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a case management tele-visit and met with Administrator Carlo Basilio. Due to COVID-19 preventive measures, a facility visit has been suspended.

The purpose of this case management was to assess the facility's request for a total care exception for resident, R1.

At 2:11 PM, LPA observed R1 in a reclined position in bed. R1 was awake and was interviewed. R1 stated R1 is able to raise both of R1's arms and reposition self with much effort. R1 demonstrated raising both arms and slowly tilting body left and right. R1 stated it makes R1 tired and R1 needs assistance with holding utensils when eating because it will take R1 a long time to finish R1's meals. R1 also demonstrated moving legs and feet.

Facility records were reviewed. Based on R1's physician's report, R1 needs assistance with all activities of daily living. Facility has a repositioning schedule for R1. LPA advised facility to have a log sheet of R1's repositioning schedule and for facility staff to be observant of skin conditions, including pressure injuries.

Based on today's assessment, a total care exception is not needed for R1. Administrator was advised to re-submit a new exception request should R1's functional capabilities change.

No deficiencies were cited. Exit interview conducted with Administrator. A copy of this report was provided electronically for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
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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