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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294287
Report Date: 08/29/2024
Date Signed: 09/05/2024 10:34:27 AM

Document Has Been Signed on 09/05/2024 10:34 AM - 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/
DIRECTOR:		BASILIO, CARLOFACILITY TYPE:
740
ADDRESS:2845 WESTBRANCH DRIVETELEPHONE:
(408) 528-1325
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Staff, Leonida (Nida) DifuntorumTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted an unannounced case management visit to continue annual inspection from yesterday 8/28/2024. LPAs spoke with Licensee, Carlo Basilio over the phone and stated the purpose of today's visit. Licensee stated he could not be present at the facility due to scheduled appointment and Licensee gave verbal authorization for staff Leonida (Nida) Difuntorum to sign today's report on his behalf. LPA Rai observed 2 staff and 3 residents at the facility.

Fire extinguisher was last serviced on 9/27/2019. Per Licensee, new fire extinguisher was purchased but could not provide receipt during yesterday's visit (8/28/2024).

Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills which were conducted at the facility were not provided during today's visit. Per Licensee, staff are not aware where the disaster drill records are kept.

During yesterday's inspection, LPA Rai reviewed facility records for 2 staff (S1-S2) and 2 residents (R1-R2). LPA Rai observed 2 out of 2 staff files did not contain SOC341A Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders. LPA Rai did not observe staff training provided for reporting suspected abuse of dependent adults and elders. LPA Rai observed 2 out of 2 resident files did not contain signed Personal Rights of Residents in All Facilities. LPA Rai observed 2 out of 2 resident files did not contain weight records where staff would measure resident's weight in pounds (lbs) or measurements of arms and/or thigh. LPA Rai observed 2 out of 3 resident files did not have signed Appraisal/Needs and Services Plan signed by resident and/or resident's responsible party.
During todays visit, LPAs reviewed facility file for R3. LPAs observed R3's facility file did not contain a Physician's Report.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435294287
VISIT DATE: 08/29/2024
NARRATIVE
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LPA Rai reviewed resident medications and central stored medication records. LPA Rai observed 1 out of 2 resident files did not a Centrally Stored Medication Record for resident (R1)'s medications which were centrally stored.

LPA Rai observed 3 residents using half-bed rails on their bed. 1 out of 3 residents is under Hospice services. 2 out of 3 resident (R1-R2) are not under Hospice services and use half-bed rail for mobility. LPA Rai observed R1 and R2's resident file did not contain written physician's orders for half-bed rails for mobility use.

LPA Rai reminded Licensee Carlo Basilio under Health and Safety Code §1569.33 (a) Every licensed residential care facility for the elderly shall be subject to unannounced inspections by the department. The department shall inspect these facilities as often as necessary to ensure the quality of care provided.

LPAs cited the deficiencies under CCR 87405 Administrator - Qualifications and Duties. Licensee/Administrator shall have knowledge of and ability to conform to the applicable laws, rules and regulations, such as Title 22 regulations and Health and Safety Code.
When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. Licensee and Administrator shall continue to work with licensing agency staff to remain professional during unannounced inspection visits.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. All Plan of Corrections (POC) for Type B deficiencies cited during today's visit will be due on Thursday, September 5th, 2024. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with staff Leonida (Nida) Difuntorum and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 09/05/2024 10:34 AM - It Cannot Be Edited


Created By: Simranjit Rai On 08/29/2024 at 10:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 435294287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited

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87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Based on interview and observation, fire extinguisher inspected in the facility were last serviced on 09/27/2019 and a new fire extinguisher was purchased last year but no receipt was provided which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/05/2024
Section Cited

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§15655 Training on elder and dependent adult abuse;...all staff being trained a written copy of the reporting requirements and a written notification of the staff's confidentiality rights as specified in Section 15633.
This requirement is not met as evidenced by:
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Based on record review and interview, the licensee did not comply with the section cited above in 2 out of 2 staff files did not contain SOC341A which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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Page: 3 of 7
Document Has Been Signed on 09/05/2024 10:34 AM - It Cannot Be Edited


Created By: Simranjit Rai On 08/29/2024 at 10:17 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 435294287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited

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87486 Personal Rights (b)(1)(A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.
This requirement is not met as evidenced by:
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Based on interview and record review the licensee did not comply with the section cited above in 2 out of 2 resident files did not contain a signed copy of Personal Rights of Residents in All Facilities which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/05/2024
Section Cited

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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes … such as unusual weight gains or losses … the licensee shall ensure that such changes are documented …
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Based on record review, ADM did not keep a record of resident’s weight gains or losses to regularly observe any changes, which pose/poses a potential health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2024 10:34 AM - It Cannot Be Edited


Created By: Simranjit Rai On 08/29/2024 at 10:27 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 435294287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited

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87463(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.

This requirement is not met as evidenced by:
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Based on record review and interview, 2 out of 2 resident files did not contain Appraisal/Needs and Services Plan and Individual Service Plan signed by resident and/or responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/05/2024
Section Cited

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(k)(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above wherein 1 out of 2 resident’s medications which are centrally stored were not recorded and maintained poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/05/2024 10:34 AM - It Cannot Be Edited


Created By: Simranjit Rai On 08/29/2024 at 10:37 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 435294287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited

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87608(a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

This requirement is not met as evidenced by:
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Based on observation, interview, and record review 2 out of 2 residents did not have a physician's order on file for the use of half bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/05/2024
Section Cited

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(c) A facility shall conduct a drill at least quarterly for each shift....Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
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Based on observation and record review, the facility staff could not provide documentation on the disaster drills conducted at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/05/2024 10:34 AM - It Cannot Be Edited


Created By: Simranjit Rai On 08/29/2024 at 10:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 435294287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited

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87458 (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.
This requirement was not met as evidenced by:
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Based on observation and record review, resident R3's file did not contain LIC 602 Physician's Report which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/05/2024
Section Cited

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(d)The administrator shall have the qualifications...If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
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Based on observation, interview &record review, the Licensee/Administrator did not comply with section cited above by not maintaining staff and resident files, maintaining fire extinguisher, maintaining records of disaster drill which poses/ posed a potential health, safety or
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(con't) personal rights risk to persons in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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