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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803678
Report Date: 09/29/2023
Date Signed: 10/03/2023 12:12:56 PM


Document Has Been Signed on 10/03/2023 12:12 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rustom Neil Lomboy, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. inspection for this facility and met with Administrator, Neil Lomboy (NL).The facility currently provides care for 6 residents. There were 2 care staff on site at the time of inspection.

LPA arrived at the facility and was allowed access. Administrator arrived shortly and toured the facility with LPA. Facility was at a comfortable temperature. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 04/03/2023. Smoke and carbon monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Care staff have current CPR and 1st Aid training on file. LPA observed live-in staff bedroom to be locked and secured.

Toxins are stored in a locked cabinet in the facility garage and under bathroom and kitchen sinks and found to be secured. There was a supply of hygiene products and paper products available for resident use. All residents bedrooms have lighting & appropriate furnishings. Water temperature was measured at faucets accessible to residents and was measured at 117.4 degrees F which is within regulation between 105 and 120 degrees F.

Continued......
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GOLD COAST CARE HOME
FACILITY NUMBER: 486803678
VISIT DATE: 09/29/2023
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Continued......

Facility has submitted Infection Control Plan. Facility has qualified for a Community Care Expansion Grant and will be receiving some renovations including flooring, bathroom upgrades and kitchen cabinets within the next few months.

LPA requested the following documents be sent to CCL by 10/15/23:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
Copy of Certificate of Liability Insurance
Updated Lease Agreement

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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