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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294287
Report Date: 08/28/2024
Date Signed: 08/28/2024 05:05:50 PM


Document Has Been Signed on 08/28/2024 05:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Licensee, Carlo BasilioTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Licensee, Carlo Basilio and stated the purpose of today's visit. LPA Rai observed 2 staff and 2 residents at the facility and 1 resident was out of the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed a shed used for storage space and not habitual space. In the garage, LPA Rai observed multiple mattress and personal items for staff S1. Licensee stated the garage is not being used as habitual space.

LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms. 4 Out of 4 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 109.2 - 109.4 degrees F.

LPA Rai will return another day to complete annual inspection.

This report was reviewed with Licensee, Carlo Basilio and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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