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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601449
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:48:35 PM


Document Has Been Signed on 12/08/2022 03:48 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: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: 4DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Corazon Nunez, LicenseeTIME COMPLETED:
04:00 PM
NARRATIVE
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On 12/8/2022 at 2:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with caregiver, Nielgar Buton and explained the purpose of the visit. Licensee, Corazon Nunez arrived 40 minutes later.

Upon entry, staff did not check LPA's temperature, but later checked LPA's temperature. LPA was asked to fill out visitor's log. LPA observed hand sanitizer at screening station. LPA toured facility including but not bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPA observed cough etiquette and physical distancing posted in the common areas. All sinks were equipped with soap and paper towel. Hot water was measured at 111.1 degrees F in the hallway bathroom.

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

At 2:15PM, LPA observed an unlocked mallet and pizza cutter in the kitchen. Under the sink cabinet that had knives and cleaning supplies were unlocked. LPA observed unlocked vitamins in staff room. Staff locked up mallet, pizza cutter, under the sink cabinet, and supplements during inspection.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency may result in 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: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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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Document Has Been Signed on 12/08/2022 03:48 PM - It Cannot Be Edited

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: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 unlocked mallet, pizza cutter, knives/cleaning supply cabinet, and vitamins which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Staff locked up mallet, pizza cutter, under the sink cabinet, and supplements during inspection.

Deficiency cleared.
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: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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