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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201224
Report Date: 04/06/2023
Date Signed: 04/06/2023 01:46:34 PM

Document Has Been Signed on 04/06/2023 01:46 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 LIVING GUEST HOMEFACILITY NUMBER:
019201224
ADMINISTRATOR:AYE, THINNFACILITY TYPE:
740
ADDRESS:9450 MOUNTAIN BLVDTELEPHONE:
(510) 509-4635
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 6CENSUS: 0DATE:
04/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Thinn Aye, AdministratorTIME COMPLETED:
01:55 PM
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On 4/06/23 at 12:45 PM, Licensing Program Analyst (LPA) G. Clark arrived unannounced to conduct pre-licensing inspection. LPA met with Thinn Aye, Administrator and explained the purpose of the visit. The existing facility currently has 4 residents.

LPA toured facility including but not limited to: bedrooms, bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed. There is sufficient lighting throughout facility. Room temperature was maintained at 71 degrees F and hot water temperature was maintained at 109.1 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 1/29/23.

LPA completed COMP 3 during visit. Administrator demonstrated adequate knowledge of RCFE regulations.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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