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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600323
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:00:37 PM


Document Has Been Signed on 06/13/2024 03:00 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:GOLDEN CARE HOMEFACILITY NUMBER:
075600323
ADMINISTRATOR:DAGDAG, MYRNA R.FACILITY TYPE:
740
ADDRESS:3579 SKYLARK DRIVETELEPHONE:
(925) 687-7394
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 1DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Merna DagdagTIME COMPLETED:
03:15 PM
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On 6/13/2024, Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Merna Dagdag and explained the purpose of the visit.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ Kitchen Sink was measured at 110.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 02/23/2024. Emergency Disaster Plan was last posted on 06/16/2023. First aid kit was observed to be complete.

LPA reviewed 1 residents records and 2 staff records; all were complete. LPAs also reviewed a sample of resident’s medications.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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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