015600032-12-13-2021-15-AS-DTOA-C9KURP-20211210144900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600032
Report Date: 12/10/2021
Date Signed: 12/13/2021 07:56:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME:	P & R RESIDENTIAL CARE (FOR ELDERLY)		FACILITY NUMBER:	015600032
ADMINISTRATOR:	SAN MIGUEL, PRECILLA		FACILITY TYPE:	740
ADDRESS:	32262 CREST LANE		TELEPHONE:	(510) 489-8082
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 6	DATE:	12/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Marta Dacuma, House Manager		TIME COMPLETED:	12:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tobola arrived unannounced to conduct a Required - 1 Year inspection and met with House Manager, Marta Dacuma (MD). Licensee, Precilla San Miguel was notified of the inspection and arrived later in the visit. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care for Elderly. There are 6 residents in care, none of which with a diagnose of dementia. LPA toured facility and grounds with House Manager and observed COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Staff follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours. Staff clean and disinfect the facility per shift change. House Manager stated high touched surface areas are disinfected after each use, such as the bathroom and kitchen area. resident rooms and common areas have disinfecting wipes and hand sanitizer. Bathrooms are equipped with liquid soap, paper towels and garbage cans with touch less lids. Staff understand hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Facility submitted a mitigation program plan, and plan has been reviewed. Caregivers have completed PPE training as well as N-95 Mask Fit Testing for all staff. In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. No accessible bodies of water or fire safety hazards observed. Fire Extinguisher was found to be charged and serviced 9/28/2021. Smoke and Carbon monoxide detectors were tested and fully operational. There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) -58-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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,
, CA

FACILITY NAME: P & R RESIDENTIAL CARE (FOR ELDERLY)	FACILITY NUMBER: 015600032
	VISIT DATE: 12/10/2021

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Water was measured at faucets accessible to residents and measured between 118.1 and 119.5 degrees F which is within Title 22 Regulations between 105 and 120 degrees F. Facility has contracted outside services to place a small storage shed in the backyard. Staff ensure residents avoid backyard area during the construction to prevent access to the contracted company's use of power tools. The storage shed is expected to be completed by the end of the day.

Licensee Precilla San Miguel's Administrator Certificate 6017258740 expires on 7/16/2022.

LPA requested the following updated documents to be submitted to CCLD by 12/17/2021:

LIC500 Personnel Report
LIC308 Designation of Administrative Responsibility
LIC610 Emergency Disaster Plan

Exit interview conducted with Licensee whose signature on this document confirms receipt.
Due to printer malfunction, this report was emailed to Licensee.

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) -58-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC809 (FAS) - (06/04)

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