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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600613
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:24:11 PM

Document Has Been Signed on 08/10/2023 02:24 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:NC HOMEFACILITY NUMBER:
015600613
ADMINISTRATOR:MCLAUGHLIN, TERESITAFACILITY TYPE:
735
ADDRESS:2729 DOWE AVENUETELEPHONE:
(510) 324-5622
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Teresita McLaughlinTIME COMPLETED:
02:45 PM
NARRATIVE
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On this day at around 9:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Administrator Teresita McLaughlin. LPA explained to Administrator the purpose of the visit. The facility is a Level 4C home vendored by the Regional Center of the East Bay (RCEB).

Facility has an approved fire clearance for 6 non ambulatory clients.

LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen, dining area, backyard and living area. There was sufficient lighting throughout the facility. No bodies of water were observed. There was sufficient supply of perishable and non-perishable foods. Sufficient blankets, sheets, towels, hand towels were observed. Fire extinguisher in the kitchen area was observed to be full and last inspected on 12/15/2022. First aid kit was observed complete and updated. Smoke detector and carbon monoxide were tested and observed operational.

Last fire drill was completed on July 31, 2023 and last earthquake drill was conducted on 10/30/2022. LPA reviewed P&I money and log. The facility has sufficient amount of surety bond to cover amount of money being handled at one time.

At 11 AM, LPA reviewed 5 client files and 5 staff files. At 12:30 PM, LPA reviewed medications and Medication Administration Record (MAR). At 1:15 PM, LPA interviewed 2 staff present. At 2pm , LPA interviewed 1 of 5 clients.
continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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: NC HOME
FACILITY NUMBER: 015600613
VISIT DATE: 08/10/2023
NARRATIVE
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The following records were requested to be sent to CCL by Monday, August 14 2023:
Lic 500, Lic 308, Resident Roster and Lic 400.

The following deficiencies were observed:
  • resident in Room 1 was observed sitting in the recliner blocking emergency exit
  • last earthquake drill was conducted on October 2022


Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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Document Has Been Signed on 08/10/2023 02:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/10/2023 at 01:16 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: NC HOME
FACILITY NUMBER: 015600613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 a resident sit in the recliner blocking the emergency exit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Administrator moved the resident's recliner in the living room during the visit. The deficiency is cleared.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2023 02:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/10/2023 at 01:16 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: NC HOME
FACILITY NUMBER: 015600613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review conducted, the licensee did not comply with the section cited above in not conducting earthquake drills once in every three month which poses/posed a potential health, safety or personal rights risk to persons in care. Last earthquake drill was completed in October 2022.
POC Due Date: 08/14/2023
Plan of Correction
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By POC date, Administrator will conduct earthquake drill and submit proof of training to CCL.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above in not completing earthquake drill quarterly which poses/posed a potential health, safety or personal rights risk to persons in care. Last earthquake drill was conducted in October 2022.
POC Due Date: 08/14/2023
Plan of Correction
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Administrator will conduct earthquake drill and submit proof of training to CCL by POC date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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