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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201639
Report Date: 06/17/2021
Date Signed: 06/30/2021 10:28:08 AM

Document Has Been Signed on 06/30/2021 10:28 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:GOLDEN SHORE CARE HOMEFACILITY NUMBER:
435201639
ADMINISTRATOR:QING GUOFACILITY TYPE:
740
ADDRESS:3800 RHODA DRIVETELEPHONE:
(408) 615-0880
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 6CENSUS: 5DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Qing GuoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Licensee Qing "Elena" Guo.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station and sign in sheet were present at the entrance. Hand sanitizers were available. LPA was temperature checked before entering the facility. LPA toured the facility with Licensee.

The facility was observed to be in sanitary condition.

All restrooms observed to be adequately stocked with paper towels and hand soap. Hand washing sign was observed.

A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) was in file.

LPA reviewed the current Provider information Notices and current recommendation of COVID-19 prevention controls.

Advisory notes were issued. See LIC 9102.

No deficiency cited during visit.

This report was reviewed with Licensee and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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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