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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201639
Report Date: 06/06/2024
Date Signed: 06/06/2024 11:10:20 AM

Document Has Been Signed on 06/06/2024 11:10 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:GOLDEN SHORE CARE HOMEFACILITY NUMBER:
435201639
ADMINISTRATOR/
DIRECTOR:
QING GUOFACILITY TYPE:
740
ADDRESS:3800 RHODA DRIVETELEPHONE:
(408) 615-0880
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 6CENSUS: 6DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Administrator Qing GuoTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Qing Guo. During the visit, LPA observed 6 residents and 2 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 4 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA observed the storage shed in the backyard being used as storage.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured to range from 109-111 degrees F in resident bathrooms.

Fire extinguisher was serviced in October 9, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 05/15/2024. LPA requested to review the 3rd & 4th quarter drill in 2023 and the 1st quarter drill in 2024. ADM stated she conducted the drills but could not produce documentation showing the drills had been conducted.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents.

A Deficiency is being cited during today's visit. This report was reviewed with Administrator Qing Guo and a copy of the signed report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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Document Has Been Signed on 06/06/2024 11:10 AM - It Cannot Be Edited


Created By: Manuel Monter On 06/06/2024 at 10:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: GOLDEN SHORE CARE HOME

FACILITY NUMBER: 435201639

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA requested to review facility fire/earthquake drill log. The facility's last drill was on 05/15/2024. LPA requested to review see documentation the 3 previous drill had been conducted. ADM stated she conducted the drills but could not produce documentation showing the drills had been conducted. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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ADM stated she will ensure the facility conducts a drill at least quarterly and have documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the hand written letter of understanding to LPA by POC date, June 13, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


LIC809 (FAS) - (06/04)
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