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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803678
Report Date: 09/16/2021
Date Signed: 09/16/2021 02:45:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GOLD COAST CARE HOMEFACILITY NUMBER:
486803678
ADMINISTRATOR:LOMBOY, RUSTOM NEILFACILITY TYPE:
740
ADDRESS:443 OLD RIVER DRIVETELEPHONE:
(707) 631-8946
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 6DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Neil Lomboy, LicenseeTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Licensee, Neil Lomboy (NL).The facility currently provides care for 6 residents some with a care of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Staff, Alex Ordonez (AO); Facility was at a comfortable temperature. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 4/8/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. All staff have current CPR and 1st Aid training on file.

Toxins are stored in a locked cabinet in the facility garage and under bathroom and kitchen sinks. LPA observed bleach cleaning product unsecured under kitchen sink. LPA found that the padlock for the kitchen sink was damaged. The lock was immediately replaced and cleaning product was secured. There was a supply of hygiene products and paper products available for resident use. All residents bedrooms have lighting & appropriate furnishings. LPA observed a plank of wood holding residents R1's & R2's bedroom closed. LPA explained the fire hazard risk and the plank was immediately removed. Water temperature was measured at faucets accessible to residents and was measured between 105 and 108 degrees F which is within regulation between 105 and 120 degrees F.

Infection Control:
Facility has submitted a mitigation program plan which has been reviewed. 5 of 6 residents and all staff are vaccinated with no symptoms. Surveillance testing is conducted and modified with one staff tested per month. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and clients are screened for temperature and symptoms on a daily basis.

Appeal Rights given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GOLD COAST CARE HOME
FACILITY NUMBER: 486803678
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 4 exits which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2