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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601156
Report Date: 04/03/2024
Date Signed: 04/03/2024 02:44:31 PM


Document Has Been Signed on 04/03/2024 02:44 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 OASISFACILITY NUMBER:
015601156
ADMINISTRATOR:ZARAGOSA, EUFROCINA M.FACILITY TYPE:
740
ADDRESS:2312 - 10TH ST.TELEPHONE:
(510) 527-1073
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:10CENSUS: 0DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:EUFROCINA ZARAGOSA, ADMINISTRATORTIME COMPLETED:
03:15 PM
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LPA Carol Fowler attempted to conduct an unannounced annual visit on 1/13/2024 at 9:30am. LPA arrived at the home, tried to enter the front yard but the gate was locked. There was no car located in the driveway. LPA attempted to call the facility there was no answer, LPA then attempted to call the Licensee (mobile number) but call went straight to voicemail, LPA left a message on both phone lines.

LPA Carol Fowler made a 2nd attempt to conduct an unannounced annual visit on 1/13/2024 at 2:30pm. The gate at the facility was still locked.

LPA will arrive at a later date to conduct an annual required visit.

On 04/3/2024 at 1:30 PM, Licensing Program Analyst (LPA) Carol Fowler arrived announced to conduct a 1 Year Annual Inspection, LPA was greeted by the Administrator, Eufrocina Zaragosa (ADM) and explained the purpose of the visit.

The facility is in disrepair (leaking pipes, buckling floors, Bosch Security Alarm System issues) there are no residents at the facility. Administrator will make corrections/renovations to the facility before accepting any residents. Administrator will reach out to the Department (LPA) Analyst as soon as the renovations are complete.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. The facility consists of five (5) total bedrooms, and three (3) bathrooms. No bodies of water observed. A comfortable temperature is maintained.

Continue on LIC809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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 OASIS
FACILITY NUMBER: 015601156
VISIT DATE: 04/03/2024
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Continue from LIC 809

LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 112.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors was in operating condition during visit. Fire extinguisher was last serviced on 03/25/2022. Emergency Disaster Plan was not posted. First aid kit was observed to be complete.

The following forms are to be updated and submitted to CCLD once operation resumes

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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