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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200388
Report Date: 09/21/2026
Date Signed: 09/21/2026 04:36:45 PM

Document Has Been Signed on 09/21/2026 04:36 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BUTTONS ELDERLY CARE LLCFACILITY NUMBER:
079200388
ADMINISTRATOR/
DIRECTOR:		SHIRLEY VIRDENFACILITY TYPE:
740
ADDRESS:1448 BUTTONS COURTTELEPHONE:
(925) 354-9448
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
09/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:38 PM
MET WITH:Nicollette Sykes, Caregiver TIME VISIT/
INSPECTION COMPLETED:
04:57 PM
NARRATIVE
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On 09/21/2026 at 1:38PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Nicollette Sykes, caregiver, and explained the purpose of the visit. The Administrator currently holds a certificate (#7007630740) Expires 05/02/2027. The facility’s fire clearance was approved for two (2) ambulatory and four (4) non ambulatory residents.

LPA toured the facility with Shirley Virden, Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two and half (2 1/2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the resident’s shared bathroom was measured at 108.1 degrees Fahrenheit. One (1) out of three (3) toilets has grab bars. Residents’ bathtubs/showers are equipped with grab bars and nonskid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit.

Fire extinguisher was last serviced on 06/16/2026. Emergency Disaster Plan was last posted on 07/23/2026. First aid kit was observed to be complete. Fire drill was last conducted on 07/21/2026.

Continued LIC809C.

Harpreet Humpal
Tonica Syess-Gibson
DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2026
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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Document Has Been Signed on 09/21/2026 04:36 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/21/2026 at 03:50 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: BUTTONS ELDERLY CARE LLC
FACILITY NUMBER: 079200388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(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 evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a broken kitchen cabinet which poses/posed a potential , safety or personal rights risk to persons in care.
POC Due Date: 09/30/2026
Plan of Correction
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Licensee agreed to repair or replace kitchen cabinet and send photo email to CCLD by POC date.
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

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 in not having toilet grab bars on two(2) out of three (3) toilets which poses a potential, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2026
Plan of Correction
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Licensee agreed to install grab bars on all toilets and will send a photo email to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2026


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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BUTTONS ELDERLY CARE LLC
FACILITY NUMBER: 079200388
VISIT DATE: 09/21/2026
NARRATIVE
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Continued from LIC809

LPA reviewed six (6) residents records and four (4) staff records, they were all current and complete.

The following forms to be updated and submitted to CCLD by 09/28/2026:

  • LIC 500 Personnel Report
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC610E Emergency Disaster Plan
  • LIC308 Designation of facility responsibility

LPA observed the following deficiencies:

  • At 2:17PM, LPA observed facility does not have grab bars on two (2) of the three (3) toilets.
  • At 2:21PM, LPA observed a broken kitchen cabinet door.
  • At 3:23PM, LPA observed R2 does not have a doctor order for the half bed rails

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted and a copy of this report & appeal rights provided to Noah Lake.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2026 04:36 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/21/2026 at 04:27 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: BUTTONS ELDERLY CARE LLC
FACILITY NUMBER: 079200388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(1)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not having R2's doctor orders for half bed rails which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 09/30/2026
Plan of Correction
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Licensee agreed to obtain a doctor's order for R2's half bed rails or remove half bed rails and send photo email 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2026


LIC809 (FAS) - (06/04)
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