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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200978
Report Date: 05/04/2022
Date Signed: 05/04/2022 01:31:39 PM

Document Has Been Signed on 05/04/2022 01:31 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 LIVINGFACILITY NUMBER:
079200978
ADMINISTRATOR:PRAMOD, KAVITHAFACILITY TYPE:
740
ADDRESS:2296 INDIAN SPRINGS DRTELEPHONE:
(510) 331-5774
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
05/04/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Pramod Balanandan, Backup Administrator TIME COMPLETED:
01:45 PM
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On 5/4//2022 Licensing Program Analyst (LPA) L. Ibo conducted a health and safety check as a result of department receiving a priority 2 complaint. LPA met with Pramod Balanandan, Backup Administrator. Facility has census of 6, LPA observed 5 residents during the visit. One resident observed relaxing at the living room and other resdients are in their bedrooms. Facility has 2 hospice residents during LPA’s visit.

During the health and safety check, LPA toured the facility inside and outside, LPA inspected common areas, bathrooms, kitchen and dining. LPA observed smoke detectors and carbon monoxide detector throughout facility. Water temperature was checked at one common bathroom with a temperature of 107.7 degrees Fahrenheit. Enough food supplies were observed. Facility is maintained at a comfortable temperature for the residents in care. First aid kit was observed to be complete. Fire Extinguisher last service date was Oct. 22, 2021

LPA 2 residents in care, both residents stated that they feel fine and comfortable living at the facility. LPA observed residents appeared to be well groomed, neat and comfortable. Facility appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies were cited today.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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