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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200978
Report Date: 11/12/2024
Date Signed: 11/12/2024 03:02:28 PM

Document Has Been Signed on 11/12/2024 03:02 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:GOLDEN NEST ASSISTED LIVINGFACILITY NUMBER:
079200978
ADMINISTRATOR/
DIRECTOR:		PRAMOD, KAVITHAFACILITY TYPE:
740
ADDRESS:2296 INDIAN SPRINGS DRTELEPHONE:
(510) 331-5774
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
11/12/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:26 PM
MET WITH:Francis Bacus, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:23 PM
NARRATIVE
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On 11/12/2024 at 1:26PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a Case Management Legal/ Non-compliance visit. LPA met with care staff, Francis Bucas. Francis contacted Administrator via telephone, LPA was informed by Kavitha Administrator, of being at work and gave authorization to Francis Bucas, care staff to sign reports.

LPA observed that care staff was sitting with two residents watching television when LPA entered the facility.

LPA did a walk through the facility including bathrooms, kitchen, living room, and outdoor area.
LPA observed two (2) residents sitting in the common area watching television and two (2) residents in their bedroom in the bed with television on.

LPA requested staff files for review, care staff stated she didn’t have the key and contacted Kavitha Pramod via telephone. Kavitha explained that the key is with her and that she will leave the key tomorrow with staff. LPA explained to Administrator, the importance of files being readily accessible to Licensing for review during all visits.

Continue on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978
VISIT DATE: 11/12/2024
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Continue from LIC809

LPA couldn’t review and confirm if the facility conducted two (2) hours of staff training on each of the topics below:
1. Observation of resident(s) on recognizing signs and symptoms of residents change of condition
2. When to call 9-1-1 after resident/s unusual incident and properly responding to residents' emergencies.
3. Training on reporting requirement to timely inform appropriate parties such as but not limited to; CCLD, residents’ responsible parties, Ombudsman, etc.
4. Training for recognizing non-verbal cues of pain for residents in care.

At 2:00PM LPA observed staff and residents’ files were inaccessible for review due to being locked in a cabinet during visit.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted with Francis Bucas. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
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Document Has Been Signed on 11/12/2024 03:02 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 11/12/2024 at 02:36 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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2024
Section Cited
CCR
87412(f)

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87412 Personnel Records
f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
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Administrator agreed to send a self certifying email to CCLD stating keys to all files will be available at the facility at all times by POC date
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Based on observation, the licensee did not comply with the section cited above in having Personnel Records available to licensing agency to inspect, audit, and copy upon demand during normal business hours. which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
11/19/2024
Section Cited
CCR87506(d)

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87506 Resident Records
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements

This requirement is not met as evidenced by:
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Administrator agreed to send a self certifying email to CCLD stating keys to all files will be available at the facility at all times by POC date
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Based on observation, the licensee did not comply with the section cited above in having Residents Records available to licensing agency to inspect, audit, and copy upon demand during business hours 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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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