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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201411
Report Date: 04/16/2025
Date Signed: 04/16/2025 07:34:34 PM

Document Has Been Signed on 04/16/2025 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOLDEN STAY LLCFACILITY NUMBER:
079201411
ADMINISTRATOR/
DIRECTOR:		CUEVA, JOY DELAFACILITY TYPE:
740
ADDRESS:2968 BONNIE LANETELEPHONE:
(925) 947-1042
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 3DATE:
04/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Joy Dela Cueva, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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On 04/16/2025 at 2:55 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Pre-Licensing inspection. LPA met with Caregiver, and explained the purpose of the visit. phoned the Administrator, Joy Dela Cueva to inform. Joy arrived shortly and called the pending Licensee, Gina Te, to inform of the pre-licensing visit. LPA spoke with Gina, that stated they give authorization to Joy to sign the reports. The facility currently has three (3) residents. Administrator Certificate #7004869749 Expires 06/25/2026.

LPA toured facility with Joy including but not limited to six (6) bedrooms, two (2) bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 73 degrees F. and hot water temperatures was measured at 113.4 degrees F (Bathroom #1) and 114 degrees F (Bathroom #2). LPA observed 2 days supply of perishable and one week supply of non-perishable foods. First-aid kit was observed to be incomplete. Emergency Disaster Plan, contact information and personal rights were observed posted in common areas. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 08/21/2024.



LIC809-C Continued...
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLDEN STAY LLC
FACILITY NUMBER: 079201411
VISIT DATE: 04/16/2025
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LIC809-C (Page3)

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 3:25 PM LPA observed in detached garage three (3) rooms that included windows and hardwood floors: Room 1: a bed, storage file cabinets; Room 2: table, couch, fan, boxes and other items; and Room 3: desk, desk chair, file cabinets, hung wall painting on the wall. In this space there was also a lounge chair in the front entrance and refrigerated freezer

At 3:30 PM LPA observed in rear back yard area a ladder laying on the ground against the shed, a shower chair, dried roller paint brush, dried paint tray, 1/2 bed rail, metal, 2 other white items laying on the ground against the side of the shed.

At 3:31 PM LPA observed a medication cabinet covered with a plastic tarp located behind the rear of the shed storage.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. Updated facility sketch submitted to CCLD that indicates the use of the three (3) rooms located in detached garage. Fire Inspection will have to be scheduled and complete a new inspection of detached garage.

2. COMP III Presentation

Pre-Licensing is incomplete with deficiencies to be resolved by 04/23/2025. A follow up Pre-licensure LIC809 will be generated upon resolution of deficiencies.



Exit interview conducted and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/16/2025 07:34 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 04/16/2025 at 06:19 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 STAY LLC
FACILITY NUMBER: 079201411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by having ladder, 1/2bed rail, shower chair, dried roller paint brush, paint tray, metal located in rear back yards which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Administrator removed the items. 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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