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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600323
Report Date: 07/09/2021
Date Signed: 07/09/2021 03:45:19 PM

Document Has Been Signed on 07/09/2021 03:45 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 CARE HOMEFACILITY NUMBER:
075600323
ADMINISTRATOR:DAGDAG, MYRNA R.FACILITY TYPE:
740
ADDRESS:3579 SKYLARK DRIVETELEPHONE:
(925) 687-7394
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 6CENSUS: 3DATE:
07/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Myrna Dagdag, Licensee/AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On 7/9/2021 at 12:55PM, Licensing Program Analysts (LPAs) G. Luk and C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPAs met with Licensee, Myrna Dagdag and explained the purpose of the visit.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPAs observed cough etiquette, sign & symptoms, and social distance posted in the common areas. Hand washing posters were posted at hand washing stations.

During record review, LPAs observed visitors log. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed food and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 1:10PM, LPAs observed unlocked knives, lighters, matches, and cleaning supplies.
-At 1:20PM, LPAs observed facility did not document resident observation. Only 1 page of April 2021 notes were observed in the notebook.
-At 1:30PM, LPAs observed administrator did not have knowledge regarding CCLD regulations/PINs. Facility have not been documenting staff/resident temperature screening and staff have not been conducting COVID-19 surveillance testing.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2021
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 07/09/2021 03:45 PM - It Cannot Be Edited


Created By: Grace Luk On 07/09/2021 at 02:44 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 CARE HOME
FACILITY NUMBER: 075600323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having unlocked knives, matches, lighters, and cleaning supplies which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/10/2021
Plan of Correction
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Staff locked up knives, matches, lighters, and cleaning supplies during inspection.

Deficiency cleared during inspection.
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:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2021


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 07/09/2021 03:45 PM - It Cannot Be Edited


Created By: Grace Luk On 07/09/2021 at 02:44 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 CARE HOME
FACILITY NUMBER: 075600323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not documenting resident's changes of condition which poses a potential health and safety risk to persons in care.
POC Due Date: 07/21/2021
Plan of Correction
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Licensee has agreed to re-train all staff on documenting resident's changes of condition regularly and submit staff sign-in sheet to CCLD by POC date.
Type B
Section Cited
CCR
87405(d)(2)
Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not having knowledge of current CCLD guidelines/PINs which poses a potential health and safety risk to persons in care.
POC Due Date: 07/21/2021
Plan of Correction
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Licensee has agreed to review CCLD guidelines/PINs and submit self-certification to CCLD by POC 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2021


LIC809 (FAS) - (06/04)
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