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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200971
Report Date: 01/09/2025
Date Signed: 01/09/2025 10:52:20 AM

Document Has Been Signed on 01/09/2025 10:52 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOLF VIEW HOMEFACILITY NUMBER:
079200971
ADMINISTRATOR/
DIRECTOR:		HIPOLITO, LORICAFACILITY TYPE:
740
ADDRESS:332 PEBBLE BEACH DR.TELEPHONE:
(925) 418-5613
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
01/09/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH: Licensee Lorica HipolitoTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 01/09/2025 at 9:30AM, Licensing Program Analysts (LPAs) James Sampair and Tonica Syess-Gibson arrived unannounced to conduct a Case Management visit as a follow up to the 6/11/2024 Non-Compliance Conference with the Licensee Lorica Hipolito. Upon entry, the LPAs stated the purpose of the visit to the Licensee.

The LPAs inspected the interior and exterior of the facility, including the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, garage, and the grounds of the facility. There was a minimum of 7 days of nonperishable and 2 days of perishable foods at the facility. The water temperature was measured at 111.5 degrees, and the living room temperature was 75 degrees Fahrenheit. The fire extinguisher was last serviced on 02/27/2024. The carbon monoxide and smoke detectors were fully operational. The LPAs observed required postings in the facility, including the Residential Care Facility for the Elderly Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy.

The LPAs reviewed facility records and five (5) residents records they were all complete.

No deficiencies cited during visit.

Exit interview conducted, a copy of this report provided to Licensee, Lorica Hipolito.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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