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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200978
Report Date: 01/30/2024
Date Signed: 01/30/2024 07:34:50 PM

Document Has Been Signed on 01/30/2024 07:34 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: 5DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Estrella Bumanglag, CaregiverTIME COMPLETED:
07:50 PM
NARRATIVE
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On 1/30/2024 at 3:30PM, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPAs met with Caregiver Estrella Bumanglag, and explained the purpose of the visit. LPAs spoke with Administrator Kavitha Pramod via telephone. At 4:35PM the Licensee Pramod Balanandan arrived. The facility’s fire clearance was approved for four (4) non-ambulatory and two (2) bedridden residents.

LPAs toured the facility with Administrator 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. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs 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 132.6 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 8/30/2023. Emergency Disaster Plan was last posted on 02/2019. First aid kit was observed to be complete. Fire drill was last conducted on 01/15/2024.

Continued on LIC809.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978
VISIT DATE: 01/30/2024
NARRATIVE
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Continued from LIC809.

Five (5) staff records were reviewed and four (4) our of five (5) were not first aid certified, and one (1) staff was not associated or had a file to review. LPAs reviewed all six (6) resident records.

LPA requested the following documents to be submitted to CCLD by 02/06/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance

LPA observed the following deficiencies:
  • At 3:35pm, LPAs observed during record review and interview S1 was not associated to the facility.
  • At 3:44pm LPAs observed unlocked kitchen cabinet with medication.
  • At 3:45pm LPAs observed unlocked kitchen drawer with knives.
  • At 3:54pm LPAs observed water temperature in shared restroom to be 132.6 Fahrenheit.
  • At 5:28pm LPAs observed bedridden resident located in room number four(4). Per fire clearance bedridden should reside in either bedroom #2 or #3.
  • At 5:56pm LPAs observed during record review four (4) staff were not first aid certified.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978
VISIT DATE: 01/30/2024
NARRATIVE
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Continued from LIC809C.

*The total amount of civil penalties assessed on today's date is $100.00 for staff not being associated.*

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, LIC421BG, and the report provided.


SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/30/2024 07:34 PM - It Cannot Be Edited


Created By: Laura Hall On 01/30/2024 at 06:52 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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(b)(3)(B)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (3) For volunteers that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in having S1 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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3
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Administrator agreed to assoicated S1 to facility and submit association to CCLD by POC date.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in having R4 in bedroom that is not cleared for bedridden which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator will either change R4 to room that is fire cleared for bedridden, or submit an LIC200 and new facility sketch to request a fire clearance to change bedroom #4 to bedridden.
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


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Page: 4 of 7
Document Has Been Signed on 01/30/2024 07:34 PM - It Cannot Be Edited


Created By: Laura Hall On 01/30/2024 at 06:52 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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(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 medication inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Caregiver immediately locked cabinet and drawer in kitchen making medication 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


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Page: 5 of 7
Document Has Been Signed on 01/30/2024 07:34 PM - It Cannot Be Edited


Created By: Laura Hall On 01/30/2024 at 06:52 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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in having four (4) staff first aid certified which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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Administrator agreed to have all staff first aid certified and submit a copy of certification to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having doctor orders for R5 and R2 full bedrails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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Licensee removed full bedrails from R2 and R5 beds. 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


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Document Has Been Signed on 01/30/2024 07:34 PM - It Cannot Be Edited


Created By: Laura Hall On 01/30/2024 at 07:06 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: 01/30/2024

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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4
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: 01/31/2024
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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4
POC Due Date:
Plan of Correction
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3
4
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


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