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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294287
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:53:23 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: 3DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Carlo BasilioTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Carlo Basilio.

At 2:12 PM, LPA entered the facility through the facility's central entry point and was screened by staff. At 2:20 PM, a tour of the facility was conducted. COVID-19 postings were observed throughout the facility including bathrooms, living room, dining room, and kitchen. Individual air-conditioning units were observed in each resident room. 3 residents and 3 staff were present during visit.

Hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable food and at least 1 week's supply on non-perishable food supply was observed in the premises. Personal protective equipment (PPE) and disinfection supplies were available in the premises.

Per Administrator, all residents and staff are fully vaccinated against COVID-19. The facility is currently accepting visitors inside the facility. The facility's mitigation plan was reviewed.

Exit routes were observed clear and unobstructed. No open bodies of water were observed. Fire extinguishers and smoke detectors were observed.

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

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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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