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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601449
Report Date: 12/04/2024
Date Signed: 12/04/2024 05:07:46 PM

Document Has Been Signed on 12/04/2024 05:07 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/
DIRECTOR:		NUNEZ, CORAZON & MAXIMINOFACILITY TYPE:
740
ADDRESS:970 OLD OAK ROADTELEPHONE:
(925) 245-1818
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Corazon Nunez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:23 PM
NARRATIVE
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On 12/4/2024 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Maribel Zumel and explained the purpose of the visit. Administrator, Corazon Nunez arrived 4 hours later.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 6/25/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 118.6 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. LPA reviewed 4 residents and 3 staff files starting at 11:30AM. LPA interviewed 2 residents and 2 staff during inspection. LPA reviewed a sample of resident's medications starting at 2:50PM.

At 12:00PM, LPA observed two residents (R2 & R3) was identified as bedridden in the physician's reports. Both residents were not on hospice care. LPA was unable to observe the residents reposition independently. Facility does not have a bedridden fire clearance. Civil penalty of $500 is being assessed.

At 1:00PM, LPA observed S2 and S3 does not have medication training documents on file.

At 2:00PM, LPA observed facility did not complete quarterly disaster drills and last disaster drill documented was on 11/10/2023.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights was provided.
Harpreet HumpalTELEPHONE: (510) 285-3928
Grace LukTELEPHONE: (510) 286-4201
DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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Document Has Been Signed on 12/04/2024 05:07 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: 12/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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: (2) Bedridden persons

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 by not having bedridden fire clearance and obtaining bedridden residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/05/2024
Plan of Correction
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Administrator has agreed to inform fire department of two bedridden residents and submit LIC200, updated sketch, and notification to fire department to CCLD by POC date.
Civil penalty of $500 is being assessed.
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 HumpalTELEPHONE: (510) 285-3928
Grace LukTELEPHONE: (510) 286-4201

DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2024 05:07 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: 12/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having two staff complete their medication training which poses a potential health and safety risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Administrator has agreed to obtain medication training for S2 and S3. Administrator will submit training document to CCLD by POC date.
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not conducting quarterly disaster drills which poses a potential health and safety risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Administrator has agreed to conduct disaster drill and submit document 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 HumpalTELEPHONE: (510) 285-3928
Grace LukTELEPHONE: (510) 286-4201

DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024

LIC809 (FAS) - (06/04)
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