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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201224
Report Date: 02/11/2026
Date Signed: 02/11/2026 05:00:16 PM

Document Has Been Signed on 02/11/2026 05:00 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOLDEN LIVING GUEST HOMEFACILITY NUMBER:
019201224
ADMINISTRATOR/
DIRECTOR:		AYE, THINNFACILITY TYPE:
740
ADDRESS:9450 MOUNTAIN BLVDTELEPHONE:
(510) 509-4635
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 6CENSUS: 6DATE:
02/11/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Thinn Aye, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 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 02/11/2026 at 3:00 pm, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Licensee/Administrator, Thinn Aye, and explained the purpose of the visit.

While conducting complaint investigation 15-AS-20260204142916 on 02/11/2026, LPA conducted a record review and facility observations. During the visit, LPA observed that Resident 1 (R1) was residing in a room that does not have fire clearance for a bedridden resident. LPA also observed that the bedroom of Residents 2 (R2) and 3 (R3) was being used as a passageway to access the room where R1 is currently located.

Additionally, LPA observed the following:

  • Residents 1 through 6 (R1–R6) did not have completed Appraisal Needs and Services documents on file.
  • Residents 4 (R4) and 6 (R6) did not have updated Admission Agreements on file.
  • One-half bed rails were in use for Residents 1 through 4 and Resident 6 (R1–R4, R6) without physician’s orders on file.
  • Home health care plans were missing for Residents 1 (R1) and 2 (R2).
  • Resident 6 (R6) eloped on 12/11/2025. LPA received a copy of the Unusual Incident Report that Licensee Thinn Aye stated was submitted to CCLD.

LIC809-C Continued...
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2026
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 7
Document Has Been Signed on 02/11/2026 05:00 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 02/11/2026 at 01:18 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 LIVING GUEST HOME
FACILITY NUMBER: 019201224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2026
Section Cited
CCR
87202(a)(2)

1
2
3
4
5
6
7
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(2) Bedridden persons

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to submit an updated facility sketch that will include all bedrooms and bedridden. In addition, Administrator will submit notification to local fire district of bedridden resident in facility. All copies of documents will be submitted to CCLD by POC due date.
8
9
10
11
12
13
14
Based on observation, file review, interview, the licensee did not comply with the section cited above by not having a fire clearance for bedridden (R1) in a room that wasn't cleared as a bedroom per facility sketch and current fire clearance dated 10/24/22 which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Immediated Civil Penalty $500.00 assessed.
Type B
02/26/2026
Section Cited
CCR87307(a)(2)(C)

1
2
3
4
5
6
7
87307 Personal Accommodations and Services (a) Living accommodations...shall be related to the facility's function. ... provide comfortable living accommodations and privacy for the residents... The following provisions shall apply: (2) Resident bedrooms shall be provided which meet... (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to read the regulation and self certify understanding the regulation. Administrator stated that they will lock the sliding glass window that is connected between Bedroom #3 and adjacent room.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by allowing the use of R2's and R3's bedroom as a passageway to another room for R1 which poses an health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Documents will be sent to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/11/2026 05:00 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 02/11/2026 at 02:04 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 LIVING GUEST HOME
FACILITY NUMBER: 019201224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2026
Section Cited
CCR
87463(a)

1
2
3
4
5
6
7
87463 Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to complete ANS for R1-R6 and send completed signed copies to CCLD by POC due date.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above by having completed Appraisal Needs and Services (ANS) on file for R1-R6 which poses an health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
02/26/2026
Section Cited
CCR87507(e)

1
2
3
4
5
6
7
87507 Admission Agreements
(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to submit copies of updated signed admission agreements for R4 and R6 and will submit to CCLD by POC due date.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above by not having an updated Admissions Agreement on file for R4 and R6 who were transferred from another facility (same Licensee) which poses an health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/11/2026 05:00 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 02/11/2026 at 02:46 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 LIVING GUEST HOME
FACILITY NUMBER: 019201224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2026
Section Cited
CCR
87608(a)(3)

1
2
3
4
5
6
7
87608 Postural Supports
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to submit doctor's orders for postural/mobility support for R1, R2 and R3 to CCLD by POC due date.
8
9
10
11
12
13
14
Based on observation, record review and interview, the licensee did not comply with the section cited above by not having an doctor's orders on file for R1, R2 and R3 which poses an health, safety or personal rights risk to persons in care.

This requirement is not met as evidence by:
8
9
10
11
12
13
14
Type B
02/26/2026
Section Cited
CCR87623(b)

1
2
3
4
5
6
7
87623 Indwelling Urinary Catheter
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(1) Ensuring that insertion and irrigation of the catheter shall be performed by an appropriately skilled professional.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to submit a copy of home health care plan for R2's foley catheter and training record for staff caregiversby skilled health professional to CCLD by POC due date.
8
9
10
11
12
13
14
Based on observation, record review and interview, the licensee did not comply with the section cited above by not having the home health care plan on file for R2's foley catheter and caregiver training with draining the catheter bag which poses an health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/11/2026 05:00 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 02/11/2026 at 03:16 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 LIVING GUEST HOME
FACILITY NUMBER: 019201224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2026
Section Cited
CCR
87609(b)(4)

1
2
3
4
5
6
7
87609 Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to submit a home health care plan for R1's wound care and submit to CCLD by POC due date
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above by not having a home health care plan on file for R1's wound care including but not limited to physical therapy, occupational therapy and nurse aide which poses an health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
02/26/2026
Section Cited
CCR87628(a)

1
2
3
4
5
6
7
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to submit an updated Physician's Report (LIC602-A) for R1 showing that they can administer their own insulin injections or documentation that an appropriately skilled professional to CCLD by POC due date
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above by not having an appropriately skilled professional administering insulin injections for R1's diabetes which poses an health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLDEN LIVING GUEST HOME
FACILITY NUMBER: 019201224
VISIT DATE: 02/11/2026
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

LIC809-C (Page 2)

LPA obtained the following documents: updated facility sketch.

Deficiencies were observed and cited in accordance with the California Code of Regulations, Title 22 (see LIC 809D). Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted. A copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026
LIC809 (FAS) - (06/04)
Page: 7 of 7