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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440427
Report Date: 04/15/2022
Date Signed: 04/15/2022 04:09:34 PM


Document Has Been Signed on 04/15/2022 04:09 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:CHARITYS RESIDENCEFACILITY NUMBER:
011440427
ADMINISTRATOR:MARYANN AQUINO LAGURAFACILITY TYPE:
740
ADDRESS:2933 MONTEREY BLVDTELEPHONE:
(510) 482-2855
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY:6CENSUS: 4DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maryann Aquino, AdministratorTIME COMPLETED:
04:25 PM
NARRATIVE
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On 4/15/2022 starting at 1:25 p.m., Licensing Program Analysts (LPAs) Catherine Lin and Kelly Nguyen arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Maryann Aquino and disclosed the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has Mitigation Plan, Emergency and Disaster Plan on file.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· At 1:30 p.m., LPAs observed unlocked knives in the kitchen drawer.
· At 1:40 p.m., LPA observed unlocked cleaning supplies in the cabinet.
· At 1:50 p.m., LPA observed 11 bottles of unlocked medicines on the dinner table.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
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 04/15/2022 04:09 PM - It Cannot Be Edited

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: CHARITYS RESIDENCE
FACILITY NUMBER: 011440427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 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 and interview, the licensee did not comply with the section cited above. LPAs observed unlocked knives in the kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2022
Plan of Correction
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Administrator will fix the drawer lock and agreed to keep all knives locked at all time, and submit photos of the fixed lock to CCL by the POC due day.
In addition, Administrator agreed to conduct training with staff of regulation and submit a copy of training agenda and sign-in sheet to CCL by the POC due day.
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f)The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


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. LPAs observed unlocked disinfectants, cleaning supplies in the cabinet, and bottles of medicines on the dinning table which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2022
Plan of Correction
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Administrator locked up the medicines and cleaning supplies during inspection.
In addition, Administrator agreed to conduct training with staff of regulation and submit a copy of training agenda and sign-in sheet to CCL by the POC due day.

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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4