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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200978
Report Date: 01/08/2025
Date Signed: 01/08/2025 03:38:08 PM

Document Has Been Signed on 01/08/2025 03:38 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 NEST ASSISTED LIVINGFACILITY NUMBER:
079200978
ADMINISTRATOR/
DIRECTOR:		PRAMOD, KAVITHAFACILITY TYPE:
740
ADDRESS:2296 INDIAN SPRINGS DRTELEPHONE:
(510) 331-5774
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:18 AM
MET WITH:Frances Bacus, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:52 PM
NARRATIVE
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On 01/08/2025 at 10:18AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a 1-Year Required inspection. LPA met with Caregiver, Frances Bacus and explained the purpose of the visit. Frances called the Administrator, Kavitha Pramod via telephone. At approximately 11:15AM Administrator, Kavitha Pramod arrived. Administrator, Kavitha Pramod had to leave and gave authorization for Caregiver, Estrella Bumanglag to sign the reports. The facility’s fire clearance was approved for four (4) non-ambulatory and two (2) bedridden residents.

LPA toured the facility with Caregiver, Frances Bacus including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms. and three (3) 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 73 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 146.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. 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 08/03/2024. Emergency Disaster Plan was last posted on 01/02/2025. First aid kit was observed to be complete. Fire drill was last conducted on 08/26/2024.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978
VISIT DATE: 01/08/2025
NARRATIVE
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Continued from LIC809.

Five (5) staff records were reviewed and five (5) out of five (5) were first aid certified, and one (1) staff was not fingerprint cleared and associated to facility. LPA reviewed all five (5) resident records which were complete.

LPA requested the following documents to be submitted to CCLD by 01/15/2025:

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· Liability Insurance


LPA observed the following deficiencies:


· At 10:26AM LPA observed water temperature in the shared bathroom measured at 146.0 degree Fahrenheit.
· At 10:33AM, LPA observed unlocked kitchen cabinet with medications.
· At 10:35AM LPA observed unlocked kitchen cabinet knives and a lighter.
· At 11:02AM LPA observed a broken window located in the living room area.
· At 11:05AM LPA observed an exit gate in disrepair in the backyard.
· At 12:37PM LPA observed during record review and interview S1 was not fingerprint cleared and associated to the facility

Continue on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/08/2025 03:38 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/08/2025 at 01:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee did not comply with the section cited above by having uncleared staff (S1) work at the facility which poses an immediate health and safety risk to the persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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S1 was asked to leave the facility. Facility has agreed to obtain fingerprint clearance for S1 prior to S1 returning to the facility. Facility will submit correspondence with CCLD regarding S1's clearance or S1's live scan form to CCLD by POC date. Civil penalty of $500 is being assessed.
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in medications in a kitchen cabinet with a broken lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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Administrator had Caregiver remove the medications and place in another cabinet with a functioning lock. Deficiency cleared during visit.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/08/2025 03:38 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/08/2025 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having knives and a blue lighter inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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Administrator had Caregiver immediately remove knives and lighter and place in a locked cabinet in kitchen making blue lighter and knives inaccessible. Deficiency cleared during visit.
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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/08/2025 03:38 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/08/2025 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(2)
87303 Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water between 105 - 120 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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Administrator will adjust water and submit photo of hot water temperature to CCLD by POC date.
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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 01/08/2025 03:38 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/08/2025 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in a broken window in the living room area and side gate in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Administrator agreed to send CCLD a photo email of the replaced window and gate by POC date.
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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
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 NEST ASSISTED LIVING
FACILITY NUMBER: 079200978
VISIT DATE: 01/08/2025
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Continued from LIC809C.

*The total amount of civil penalties assessed on today's date is $1000.00. $500.00 for staff not being fingerprint cleared, $250.00 for repeat violation of regulation 87705(f)(1) and $250.00 for a repeat violation of regulation 87303(2).

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy the appeal rights, LIC421IM, LIC421FC and this report provided to Estrella Bumanglag.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
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