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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601123
Report Date: 02/06/2025
Date Signed: 02/06/2025 02:17:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/06/2025 02:17 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOLDEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
385601123
ADMINISTRATOR/
DIRECTOR:		ARCE, ARLENE MAGTIBAYFACILITY TYPE:
740
ADDRESS:166 FOOTE AVENUETELEPHONE:
(415) 587-2507
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 6CENSUS: 4DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Administrator - Arlene Arce MagtibayTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 02/06/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with administrator Arlene Arce Magtibay today and explained the purpose of today's visit. Currently there is 1 staff present and 4 clients. All residents are in their rooms by choice. LPA observed 3 of 4 residents.

This is a two level facility with 3 bedrooms for residents. Facility is licensed for age range 60 and over all of which must be ambulatory. All resident rooms are on the upper floor. The ground level is the garage and living quarters for the staff. LPA Vado toured the facility both inside and outside. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Laundry area is in the garage and is fully functional. Canned food supplies are primarily observed as stored in the garage locked behind cabinets. Knives are locked in the kitchen cabinet across the stove/range along with the medications. Toxic chemicals and cleaning supplies are stored in a closet in the kitchen which is observed to be locked. PPE are in place as stored in the living room area. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. Each resident room is equipped with smoke detectors. LPA observed a fire extinguisher in the kitchen with an inspection tag of 11/21/2024 which is charged and ready for use.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOLDEN RESIDENTIAL CARE HOME
FACILITY NUMBER: 385601123
VISIT DATE: 02/06/2025
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Facility has one full bathrooms for resident use. Shower floor is equipped with non-skid flooring. Based on review of all resident files, and medications all items are current and logged accurately. Administrator certificate is observed as expiring 09/12/2026.

The following updated forms are being requested to be received by 02/13/2025:

• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

There are no citations issued during today's inspection visit. Report is reviewed with Arlene and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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