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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200346
Report Date: 08/10/2022
Date Signed: 08/10/2022 12:19:42 PM

Document Has Been Signed on 08/10/2022 12:19 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 PONDFACILITY NUMBER:
079200346
ADMINISTRATOR:HAYDEN O'SHEAFACILITY TYPE:
740
ADDRESS:1296 GREENBROOK DRIVETELEPHONE:
(925) 838-1433
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 6CENSUS: 4DATE:
08/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Pamela Chan, AdministratorTIME COMPLETED:
12:25 PM
NARRATIVE
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On 8/10/2022 at 10:55 AM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPAs were greeted by Care Staff, Imelda Marasigas. Administrator, Pamela Chan later arrived at 11:30 AM.

During the Infection Control Inspection, LPAs toured facility with Care Staff, Divine Monis including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility staff were observed to be wearing proper PPE. PPEs maintained at central location and easily accessible for staff.

At 11:50 AM, LPAs reviewed 3 staff records and 3 of 3 have health screening and TB test results on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT:
-At 11:15 AM, LPAs observed orange juice and whipped cream are being stored in the pantry closet. Deficiency cleared during visit. LPAs observed staff removed items from pantry and discarded it.


REPORT CONTINUES ON 809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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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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: GOLDEN POND
FACILITY NUMBER: 079200346
VISIT DATE: 08/10/2022
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/19/2022:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • Current Administrator’s Certificate


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

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2022 12:19 PM - It Cannot Be Edited


Created By: Lizette Francisco On 08/10/2022 at 11:50 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLDEN POND
FACILITY NUMBER: 079200346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

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. LPAs observed orange juice and whipped cream were being stored in pantry closet which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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DEFICIENCY CLEARED DURING VISIT. LPAs observed staff removed items and discarded it.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures by 8/19/2022.
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 Humpal
LICENSING EVALUATOR NAME:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022


LIC809 (FAS) - (06/04)
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