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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201224
Report Date: 05/26/2026
Date Signed: 05/26/2026 11:27:46 PM

Document Has Been Signed on 05/26/2026 11:27 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOLDEN LIVING GUEST HOMEFACILITY NUMBER:
019201224
ADMINISTRATOR/
DIRECTOR:		PASCUAL, JEZRAELFACILITY TYPE:
740
ADDRESS:9450 MOUNTAIN BLVDTELEPHONE:
(510) 509-4635
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 6CENSUS: 5DATE:
05/26/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jezrael Pascual, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 05/26/2026 at 2:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management regarding a capacity increase. LPA met with Administrator, Jezrael Pascual, and explained the purpose of the visit.

LPA toured the facility with Administrator to view the floor plan for the requested capacity increase for 6 Residents. LPA observed rooms

During the visit deficiencies observed:

  • Pile of wooden drawers, materials located on front sidewalk
  • Unlocked door to laundry room with toxic chemicals unlocked: mulit-purpose disinfectant, Zep Drain Care solution, Downy Fabric Softener, Arm and Hammer Laundry Detergent.
  • Resident/Staff coming upstairs to unlicensed area and sleeping upstairs without approved fire clearance.
  • Community Care Licensing was not informed of hospice services for R5. In addition, R4 and R5 are both in shared room and there's no agreement on file that R4 grant access to the shared living space to hospice caregivers.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLDEN LIVING GUEST HOME
FACILITY NUMBER: 019201224
VISIT DATE: 05/26/2026
NARRATIVE
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LIC809-C (Page 2)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights, LIC421IM and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/26/2026 11:27 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/26/2026 at 03:45 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLDEN LIVING GUEST HOME
FACILITY NUMBER: 019201224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2026
Section Cited
CCR
87202(a)

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87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.


This requirement is not met as evidence by:
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Administrator will redirect resident(s) to first floor licensed area for sleeping and taking space. Administrator will self-certify that they have read the regulation and will comply moving forward.
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Based on observation, file review, interview, the licensee did not comply with the section cited above by not having an approved fire clearance upstairs before letting residents (R2) go upstairs, sleeping in bedroom in which poses an immediate health, safety or personal rights risk to persons in care.
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Administrator will send self-certification to CCLD by POC due date.

Immediate Civil Penalty $500.00
Type A
05/27/2026
Section Cited
CCR87309(a)

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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidence by:
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Administrator agreed to conduct an In-Service Training with staff and send sign-in sheet to CCLD by POC due date.
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Based on observation the licensee did not comply with the section cited above by not having the laundry room door locked upstairs which toxic chemicals: Laundry detergent, Downy Softener, multi-purpose disinfectant, drain cleanser were unlocked in laundry room. In which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/26/2026 11:27 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/26/2026 at 04:07 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLDEN LIVING GUEST HOME
FACILITY NUMBER: 019201224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2026
Section Cited
CCR
87303(a)

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87303 Maintenance and Operations
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidence by:
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Administrator agreed to clean up piles of wooden debris from front yard/sidewalk and send a photo to CCLD by POC due date.
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Based on observation, the licensee did not comply with the section cited above by not having piles of wood debris cleared from front yard which poses a potential health, safety or personal rights risk to persons in care.
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Type B
06/09/2026
Section Cited
CCR87632(d)(2)

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CCR 87632 Hospice Care Waiver
(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements:
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.
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Administrator sent hospice notification to CCLD for R5 during visit.

Deficiency cleared during visit.
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Based on observation, record review and interview the licensee did not comply with the section cited above by not notifying CCLD of R5 hospice care which poses a potential health, safety or personal rights risk to persons in care.
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/26/2026 11:27 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/26/2026 at 04:17 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLDEN LIVING GUEST HOME
FACILITY NUMBER: 019201224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2026
Section Cited
CCR
87633(b)

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87633 Hospice Care of Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
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Administrator agreed to submit an signed hospice care plan for R5 to CCLD by POC due date.
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Based on record review and interview the licensee did not comply with the section cited above by not having a signed hospice care plan on file for R5 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
06/09/2026
Section Cited
CCR87633(h)(5)

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87633 HospiceCare of Terminally Ill Residents (h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record:
(5) A statement signed by the resident's roommate, if any, or any resident who will share a room with a person who is terminally ill to be accepted or retained as a resident, indicating his or her acknowledgment that the resident intends to receive hospice care in the facility for the remainder of the resident's life, and the roommate's voluntary agreement to grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy, and others.
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Administrator agreed to get a signed statement from R4's responsible party and send to CCLD by POC due date.
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Based on record review and interview the licensee did not comply with the section cited above by not having a signed statement agreement on file for R4 whom shares room with R5 which poses a potential health, safety or personal rights risk to persons in care.
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2026


LIC809 (FAS) - (06/04)
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