015600912-8-26-2022-15-AS-LFII-CHNQNX-20220826121952

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600912
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:20:29 PM

Document Has Been Signed on 08/26/2022 12:20 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:	MURIEL'S RESIDENTIAL FACILITY II		FACILITY NUMBER:	015600912
ADMINISTRATOR:	IRENE M. JENKINS		FACILITY TYPE:	740
ADDRESS:	4643 HAMPSHIRE WAY		TELEPHONE:	(510) 703-8248
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	6	CENSUS: 6	DATE:	08/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Care Staff, Noel Morales		TIME COMPLETED:	12:30 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	On today’s date, at 11:20 AM, Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct an Annual Infection Control Visit. LPA and LPM was greeted by Care Staff, Noel Morales at front door entrance and explained the purpose for today's visit. During the inspection, LPA and LPM toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA and LPM observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA and LPM observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to residents in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 109.8 degrees F. Fire extinguisher was last serviced on 9/21/2021. Facilities room temperature is at 75. Carbon monoxide and smoke detector are operable. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA and LPM observed facility has a copy of their Infection Control Plan on file. Continue on Lic809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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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Document Has Been Signed on 08/26/2022 12:20 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: MURIEL'S RESIDENTIAL FACILITY II	FACILITY NUMBER: 015600912
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having non-skid matts in the residents bathrooms, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/27/2022
	Plan of Correction
1 2 3 4	Licensee agreed to purchase a non-skid matt for the bathrooms and to submit to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: MURIEL'S RESIDENTIAL FACILITY II	FACILITY NUMBER: 015600912
	VISIT DATE: 08/26/2022

NARRATIVE

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Continued on Lic-809C

The following Deficiency was observed during inspection:

At 11:30Am, LPA and LPM observed Non-skid matts in the bathrooms.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with care staff. Appeal rights given alone with report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

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