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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601156
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:25:59 PM


Document Has Been Signed on 04/28/2022 02:25 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:GOLDEN OASISFACILITY NUMBER:
015601156
ADMINISTRATOR:ZARAGOSA, EUFROCINA M.FACILITY TYPE:
740
ADDRESS:2312 - 10TH ST.TELEPHONE:
(510) 527-1073
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:10CENSUS: 0DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administartor, Eufrocina Zaragosa TIME COMPLETED:
02:35 PM
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On 04/28/2022 at 12:50 PM, Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct an Infection Control Inspection, LPA was greeted the Administrator, Eufrocina Zaragosa (ADM) and explained the purpose of the visit.

A screening station is at the entry with hand sanitizer, gloves, masks and COVID-19 signage. ADM to add COVID-19 signage throughout the facility, maintain a visitor sign-in log, and store a 30 day supply of PPE's upon operation. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. Advised ADM to install or obtain locks and/or containers for sharps and medication. Add 20 second handwashing signs and covered trash cans to shared bedrooms. Bathrooms were equipped with grab bars, soap and covered garbage cans. Hot water temperature in the shared residents' bathroom was measured at 106.5 degrees Fahrenheit. Fire extinguisher was last serviced on 04/25/2022. Smoke and Carbon Monoxide detectors observed operational and connected to alarm system. LPA observed an installed
sprinkler system. ADM to create an isolation cart in the event of a COVID-19 outbreak and maintain surplus in a centrally stored location.

The following forms are to be updated and submitted to CCLD once operation resumes:
-A copy of the facility's COVID-19 mitigation plan to be sent to CCLD on or before 05/05/2022.
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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