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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200388
Report Date: 08/29/2024
Date Signed: 08/29/2024 02:23:13 PM


Document Has Been Signed on 08/29/2024 02:23 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:SHIRLEY VIRDENFACILITY TYPE:
740
ADDRESS:1448 BUTTONS COURTTELEPHONE:
(925) 354-9448
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 6DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Shirley Virden, AdministratorTIME COMPLETED:
02:58 PM
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On 08/29/2024 at 12:28PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Shirley Virden, Administrator, explained the purpose of the visit. The Administrator currently holds a certificate (#7007630740) Expires 05/02/2025. The facility’s fire clearance was approved for two (2) ambulatory and four (4) non ambulatory residents.

LPA toured the facility with Noah Lake, Caregiver 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 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 110.8 degrees Fahrenheit. Residents’ bathrooms 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 06/19/2024. Emergency Disaster Plan was last posted on 05/22/2024. First aid kit was observed to be complete. Fire drill last conducted on 07/12/2024.

Continued LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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 3


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: 08/29/2024
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Continued from LIC809.

LPA reviewed six (6) resident records and three (3) staff records, and they were current and complete.

No deficiencies observed during visit.

The following forms to be updated and submitted to CCLD by 09/05/2024:

· 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


Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3