<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200346
Report Date: 12/28/2023
Date Signed: 12/28/2023 03:58:04 PM


Document Has Been Signed on 12/28/2023 03:58 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:GOLDEN PONDFACILITY NUMBER:
079200346
ADMINISTRATOR:HAYDEN O'SHEAFACILITY TYPE:
740
ADDRESS:1296 GREENBROOK DRIVETELEPHONE:
(925) 838-1433
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 5DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator, Pamela ChanTIME COMPLETED:
04:12 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) A. Gomez conducted an unannounced 1 Year Required visit on this date at 1:40pm. Upon arrival, LPA were greeted by Caregiver, Benjamin Filomeno. Administrator, Pamela Chan and Licensee Bernadette O'shea arrived at 1:50pm. The Administrator currently holds a certificate (#6012925740) that expires on 04/24/2024. The facility’s fire clearance is approved for six non-ambulatory of which one may be bedridden.

LPA toured the facility with Administrator, including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. LPA observed pool is secured with a fence around the perimeter. A comfortable temperature is maintained at 74 degrees Fahrenheit. 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 108.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Emergency Disaster Plan was last posted on 12/28/2023 . Fire extinguisher was last services 12/20/2023. First aid kit was observed to be complete. Disaster Drill was last conducted on 11/30/2023. LPA reviewed 4 staff records and 4 of 4 staff have current first aid certificates. LPAs reviewed 5 of 5 residents records.


Report continues on LIC 809-C

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: GOLDEN POND
FACILITY NUMBER: 079200346
VISIT DATE: 12/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 1/14/2024:

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


No deficiencies were cited during visit. Exit interview conducted an a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2