015601051-1-20-2023-15-AS-LFII-CNA3XN-20230120173838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601051
Report Date: 01/20/2023
Date Signed: 01/20/2023 05:38:56 PM

Document Has Been Signed on 01/20/2023 05:38 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:	LA CONCEPCION RESIDENTIAL CARE HOME		FACILITY NUMBER:	015601051
ADMINISTRATOR:	CONCEPCION, CRISTINA		FACILITY TYPE:	740
ADDRESS:	4419 JACINTO DR		TELEPHONE:	(510) 574-0755
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	6	CENSUS: 5	DATE:	01/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Christina Concepcion- Licensee		TIME COMPLETED:	05:45 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 1/20/2023, at 3:15 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Christina Concepcion, Licensee and explained the purpose of todays visit. During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. Common areas are disinfected frequently throughout the day. Water temperature is measured at 116.5 Degrees F in common area bathroom. Fire extinguisher was last serviced on 7/8/2021. Facilities room temperature is maintained at 68 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are functional. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. 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: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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 5

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: LA CONCEPCION RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601051
	VISIT DATE: 01/20/2023

NARRATIVE

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Continued from Lic809

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.

1. At 3:35PM, LPA observed two cockroaches in the kitchen drawer.

2. At 3:47PM, LPA observed scissors and knifes located in the kitchen accessible to residents in care.

3. At 4:00PM, LPA observed 4 residents with half bed rails with no physicians order, and 1 full bed rail with no physicians order.

Exit interview conducted with Licensee, appeal rights given, along with a copy of this report.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 01/20/2023 05:38 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: LA CONCEPCION RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705(f0(1): 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having Scissors in the drawer and knifes in the kitcken pantry unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to lock up all scissors and knifes in the pantry in the kitchen. Deficiency cleared.

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: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/20/2023 05:38 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: LA CONCEPCION RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(B)

87608: Postural Supports- (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 requesting an order from R5's physician to get approval for a full bed rail which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2023
	Plan of Correction
1 2 3 4	Licensee agreed to obtain a physicians order for a full bed rail and to submit proof of the order to CCL by POC due date.

Type B

Section Cited

CCR

87608(a)(5)(A)

87608: Postural Supports-(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed 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 obtaining physicians order(s) for R1, R2, R3, and R4 for approval for Half bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2023
	Plan of Correction
1 2 3 4	Licensee agree to obtain physicians orders for half bed rails for all residents and to submit to CCL by POC due 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	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/20/2023 05:38 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: LA CONCEPCION RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

87555(b)(27): General Food Service Requirements- (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 keeping the facility clean from cockroaches and making sure there are no insects walking around the kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2023
	Plan of Correction
1 2 3 4	Licensee agreed to remove and keep facility cleared from all insects and to submit a self-certification on General food service requirements on keeping the kitchen clean and sanitized 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: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5