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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601449
Report Date: 12/03/2021
Date Signed: 12/03/2021 05:12:15 PM

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:OLD OAK GOLDEN VILLA, LLCFACILITY NUMBER:
015601449
ADMINISTRATOR:NUNEZ, CORAZON & MAXIMINOFACILITY TYPE:
740
ADDRESS:970 OLD OAK ROADTELEPHONE:
(925) 245-1818
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 6DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Corazon Nunez, LicenseeTIME COMPLETED:
05:25 PM
NARRATIVE
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On 12/3/2021 at 3:10PM, Licensing Program Analysts (LPAs) G. Luk and J. Clancy-Czuleger arrived unannounced to conduct an Infection Control Inspection. LPAs met with staff, Marietta Bugayong and explained the purpose of the visit. Licensee, Corazon Nunez arrived 30 minutes later.

Upon entry, LPAs' temperature were checked, and LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage, and outdoor area. LPAs observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All sinks were equipped with soap and paper towel.

During record review, LPAs observed visitors log and temperature log. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed paper supplies are sufficient.

At 3:30PM, LPAs observed bad cucumbers that was leaking juices with strong odor. Staff discard the cucumbers during inspection.
At 3:45PM, LPAs observed dish detergent stored with non-perishable food supplies. Staff removed dish detergent during inspection.
At 3:46PM, LPAs observed facility did not have a 7-day supply of non-perishable food supplies.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OLD OAK GOLDEN VILLA, LLC
FACILITY NUMBER: 015601449
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having bad cucumber in the refridgerator which poses a potential health and safety risk to persons in care.
POC Due Date: 12/04/2021
Plan of Correction
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Staff discard the bad cucumbers during inspection. Deficiency cleared.
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by storing dish detergent with non-perishable food supplies which poses a potential health and safety risk to persons in care.
POC Due Date: 12/04/2021
Plan of Correction
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Staff removed the dish detergent during inspection. Deficiency cleared.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OLD OAK GOLDEN VILLA, LLC
FACILITY NUMBER: 015601449
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a 7-day supply of non-perishable foods which poses a potential health and safety risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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Licensee has agreed to purchase additional non-perishable foods or emergency foods and provide a receipt to CCLD by POC date.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6