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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200971
Report Date: 09/26/2023
Date Signed: 09/26/2023 04:50:25 PM


Document Has Been Signed on 09/26/2023 04:50 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:GOLF VIEW HOMEFACILITY NUMBER:
079200971
ADMINISTRATOR:HIPOLITO, LORICAFACILITY TYPE:
740
ADDRESS:332 PEBBLE BEACH DR.TELEPHONE:
(925) 418-5613
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
09/26/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensees Marvin Misa and Lorica HipolitoTIME COMPLETED:
05:15 PM
NARRATIVE
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On 09/26/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a health check as a result of a Priority 1 complaint. Upon entry, LPA stated the purpose of the visit to Licensees Marvin Misa and Lorica Hipolito.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, garage and outdoor area. Facility temperature was maintained at 72.5 degrees F. More than the minimum of 7 days of non-perishable and 2 days of perishable food supplies were on hand. Resident medications were kept locked in the cabinet. Smoke and Carbon monoxide detectors tested and were functional. There are no accessible bodies of water observed.

2 B-Type citations issued (refer to LIC809-D for details) .

Exit interview conducted and a copy of this report provided to Licensees via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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 09/26/2023 04:50 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GOLF VIEW HOME
FACILITY NUMBER: 079200971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2023
Section Cited
CCR
87705(c)(5)

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(e) Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
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On or before the due date, the licensee shall send LPA a digital copy of the LIC 602 (Physician's Report) for every resident with dementia and/or a change in condition dated within a year of 09/26/2023.
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Based on record review, the licensee did not comply with the section cited above for 5 out of 5 residents, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/04/2023
Section Cited
CCR87203

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87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
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On or before the due date, the Licensee shall send proof that their existing fire extinguisher has been replaced or serviced in accordance with 2013 California Fire Code 906.1.
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Based on observation, the licensee did not comply with the section cited above for their fire extinguisher that was purchased in 2019, which poses a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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