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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600923
Report Date: 12/15/2022
Date Signed: 12/15/2022 01:12:39 PM


Document Has Been Signed on 12/15/2022 01:12 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:LESLIE CARE HOME IIFACILITY NUMBER:
015600923
ADMINISTRATOR:LESLIE & DEMOCRITO JOSEFACILITY TYPE:
740
ADDRESS:3579 MONTEREY BLVDTELEPHONE:
(510) 352-6671
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 6DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Leslie Jose, AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
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On 12/15/2022 at 10:20 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Administrator, Leslie Jose and explained the purpose of the visit.
During the Infection Control Inspection, LPA toured facility with including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient two day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Common touched surfaces are disinfected at least once daily.
Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility has a 30 day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. LPA observed facility passages inside free of obstructions.

The following deficiency was observed during inspection:
-At approximately 11:30 AM LPA observed a resident that appeared to be bedridden, Administrator stated they were bedridden and on hospice. Facility did not have a proper fire clearance for bedridden resident. A civil penalty of $500 is being assessed.


Continue to 809 C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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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: LESLIE CARE HOME II
FACILITY NUMBER: 015600923
VISIT DATE: 12/15/2022
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The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties




Exit interview conducted and a copy of this report provided along with Appeal rights.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/15/2022 01:12 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: LESLIE CARE HOME II
FACILITY NUMBER: 015600923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
87202(a)(2) Fire Clearance

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(2) Bedridden persons


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 by failing to obatin fire clearance for bedridden resident which poses an immediate health, safety or personal rights risk to persons in care. LPA observed R1 bedridden, and confirmed with Administrator. However, facility does not have bedridden clearance
POC Due Date: 12/16/2022
Plan of Correction
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Administrator agreed to notify the fire department that R1 is bedridden and shall submit to licensing, an LIC200, along with a request for a fire inspection to retain a bedridden resident at facility by POC date.
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-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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