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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601123
Report Date: 11/16/2022
Date Signed: 11/16/2022 12:18:01 PM

Document Has Been Signed on 11/16/2022 12:18 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOLDEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
385601123
ADMINISTRATOR:ARCE, ARLENE MAGTIBAYFACILITY TYPE:
740
ADDRESS:166 FOOTE AVENUETELEPHONE:
(415) 587-2507
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 6CENSUS: 3DATE:
11/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Arlene ArceTIME COMPLETED:
12:30 PM
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In response to notification from administrator on 11/11/22 that corrections have been done as per prior pre-licensing visits of 11/4/22 and 9/30/22, LPA Jeung verified completion of corrections.

1. Hot water temperature tested at 107 degrees F in client bathroom (Section 87307 Maintenance/Operation)
2. Emergency signal system for clients to summon staff--who reside on ground level--in the event of an emergency is functioning properly. A wireless button is installed in each client room that transmits a visual and audible signal to staff quarters on ground level, identifying the origination room. (Section 87303)

Proof of liability insurance is pending licensure and will be submitted to CCLD within TEN DAYS of licensure. (Health/Safety Code 1569.605)


Component III orientation is completed today with Ms. Arce..

RCFE administrator certificate for Ms. Arce was sent to Administrator Certification Unit in Sacramento with proof of 40 hours of training, but renewal certificate has not yet been received.

Facility meets Title 22 physical plant requirements for licensure as Residential Care Facility for Elderly for
up to 6 ambulatory elderly residents
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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