079200978-1-31-2023-15-AS-LIBO-CNM2B3-20230131161429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200978
Report Date: 01/31/2023
Date Signed: 01/31/2023 04:14:38 PM

Document Has Been Signed on 01/31/2023 04:14 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 NEST ASSISTED LIVING		FACILITY NUMBER:	079200978
ADMINISTRATOR:	PRAMOD, KAVITHA		FACILITY TYPE:	740
ADDRESS:	2296 INDIAN SPRINGS DR		TELEPHONE:	(510) 331-5774
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 5	DATE:	01/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Kavitha Pramod, Administrator		TIME COMPLETED:	04:35 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	On 01/31/2023 at 2:35PM Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and explained the purpose of the visit with S2. LPA called Administrator Kavitha Pramod and back up Administrator Pramod Balanandan and informed them the purpose of the visit. Administrator arrived around 3:37PM. LPA observed 2 staff wearing face masks and 5 residents. Facility has 4 hospices during the visit. LPA inspected the facility inside and outside. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. COVID-19 signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. Continued on next page, LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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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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 NEST ASSISTED LIVING	FACILITY NUMBER: 079200978
	VISIT DATE: 01/31/2023

NARRATIVE

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Facility documents daily temperatures and COVID-19 symptom checks for staff, visitors, and residents. Pathways were observed to be free of obstruction and fire hazards. Adequate supplies of PPE were observed stored in the backyard shed. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants.

Administrator, the designated infection control leader and is on site at least 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 2/15/2023:
· LIC500- Updated Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan/Infection Control Plans
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC809 (FAS) - (06/04)

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