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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200971
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:08:06 PM

Document Has Been Signed on 11/14/2024 02:08 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/
DIRECTOR:		HIPOLITO, LORICAFACILITY TYPE:
740
ADDRESS:332 PEBBLE BEACH DR.TELEPHONE:
(925) 418-5613
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Licensee Lorica HipolitoTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 11/14/2024 at 9:15 AM, Licensing Program Analysts (LPAs) James Sampair and Tonica Syess-Gibson arrived unannounced to conduct a Case Management visit as a follow up to the 6/11/2024 Non-Compliance Conference with the Licensee Lorica Hipolito. Upon entry, the LPAs stated the purpose of the visit to the Licensee.

The LPAs met with Licensee to review her implementation of the Plan of How to Monitor Residents for Change of Condition the Licensee had submitted to the Department on 7/11/2024. The administrator, Felecia Hughes, hired on 7/11/2024 is on site 20 hours a week. However, the Administrator’s hours are not during business hours. The LPAs instructed the Licensee to change the hours to regular business hours (between 8:00 AM and 6:00 PM) and to ensure that the Administrator is overseeing the proper business operations. Licensee will send written plan to replace or change current Administrator hours by 11/21/2024 to LPA Tonica Syess-Gibson.

The LPAs inspected the interior and exterior of the facility, including the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, garage, and the grounds of the facility. The kitchen refrigerator was broken, and a replacement was ordered on 11/11/2024. Staff did not have the required minimum of 7 days of nonperishable and 2 days of perishable foods at the facility. At approximately 10:55 AM, the kitchen hot water temperature was measured at 137.2 degrees, and the living room temperature was 74 degrees Fahrenheit. The fire extinguisher was last serviced on 2/27/2024. The carbon monoxide and smoke detectors were fully operational. The LPA observed required postings in the facility, including the Residential Care Facility for the Elderly Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy.

The LPAs reviewed facility records and the records of 6 residents.

2 Type-A and 4 Type-B citations were issued during the inspection.

Deficiencies are cited per Title 22 California Code of Regulations as listed on the LIC 809-Ds. $250.00 Civil Penalty assessed for repeat violation of Section 87303(e)(2). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Exit interview conducted, a copy of this report, and the appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 4
Document Has Been Signed on 11/14/2024 02:08 PM - It Cannot Be Edited


Created By: James Sampair On 11/14/2024 at 11:03 AM
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: GOLF VIEW HOME
FACILITY NUMBER: 079200971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2024
Section Cited
CCR
87303(e)(2)

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87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (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 ... and not more than 120 degree F... This requirement is not met as evidenced by:
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On or before the due date, the Licensee shall send proof to LPA Tonica Syess-Gibson that the temperature has been decreased to the safe range.
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Based on observation, the licensee did not comply with the section cited above. The hot water was at 137.2 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
11/15/2024
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia (RCFE) (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:
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Cleared during visit.
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Based on observation, the licensee did not comply with the section cited above in the unlocked kitchen drawer with sharp knives, which poses an immediate 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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/14/2024 02:08 PM - It Cannot Be Edited


Created By: James Sampair On 11/14/2024 at 11:46 AM
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: GOLF VIEW HOME
FACILITY NUMBER: 079200971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2024
Section Cited
CCR
87555(b)(26)

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87555 General Food Service Requirements (RCFE) (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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On or before the due date, the Licensee shall send pictures and receipts as proof to LPA Tonica Syess-Gibson that they have obtained the required amount of food for not only the date of purchase, but also enough so that when they make their next purchase they will still have 7 days of non-perishable and 2 days of perishable food on hand to feed the 6 residents at the time of the next food purchase.
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Based on observation, the licensee did not comply with the section cited above. There was less than 7 days of non-perishable and 2 days of perishable food, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/21/2024
Section Cited
CCR87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:
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Cleared during visit.
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Based on observation, the licensee did not comply with the section cited above with food that was kept in a locked drawer, 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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/14/2024 02:08 PM - It Cannot Be Edited


Created By: James Sampair On 11/14/2024 at 12:30 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: GOLF VIEW HOME
FACILITY NUMBER: 079200971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2024
Section Cited
CCR
87303(a)

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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:
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On or before the due date, the Licensee shall send statement to LPA Tonica Syess-Gibson that the garage has been cleaned and is now odorless. Additionally, the Licensee shall make provisions that the floor of all areas within the facility have been cleaned of pet odors on a daily basis.
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Based on observation, the licensee did not comply with the section cited above. The garage smelled of dog feces and urine, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/21/2024
Section Cited
CCR87705(c)(5)(A)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) 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. (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
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On or before the due date, the Licensee shall self-certify to LPA Tonica Syess-Gibson that a completed LIC 602 and LIC 625 is in each resident's file.
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Based on record review, the licensee did not comply with the section cited above, with 3 of 6 residents had an out of date Physician's Report (LIC 602) and 0 of 6 Appraisal & Needs and Services Plans (LIC 625) for residents, 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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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