015601366-8-19-2022-15-AS-LFII-CHFSJL-20220819135517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601366
Report Date: 08/19/2022
Date Signed: 08/19/2022 01:55:44 PM

Document Has Been Signed on 08/19/2022 01:55 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:	FOOTPRINT CARE HOME		FACILITY NUMBER:	015601366
ADMINISTRATOR:	ALMOCERA, SOLEDAD		FACILITY TYPE:	740
ADDRESS:	4647 HANSEN AVENUE		TELEPHONE:	(510) 797-8719
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	6	CENSUS: 2	DATE:	08/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Care staff- Gloria Zulueta		TIME COMPLETED:	02:10 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 10:10 AM, Licensing Program Analysts (LPAs) L. Fici and C. Lin arrived unannounced to conduct an Annual Infection Control Visit. LPAs was greeted by Care staff- Gloria Zulueta outside of the facility. During the inspection, LPAs toured facility with care staff- Magdalena Calubiran, including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPAs observed paper supplies and PPEs are not sufficient. 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 109.4. Fire extinguisher was last serviced on 8/4/2021. Facility passages inside and out free of obstruction and does not pose a health and safety risk for persons in care. Continue on Lic809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FOOTPRINT CARE HOME	FACILITY NUMBER: 015601366
	VISIT DATE: 08/19/2022

NARRATIVE

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Continued on Lic809-C

The following deficiencies were observed during inspection:

At 10:11AM, LPAs observed fire alarm not functional and beeping.

At 11:00 AM, LPAs observed R1 records for care notes not updated and maintained. Care staff stopped recording progress notes on 6/8/2012.

At 11:05, Care staff told LPAs that a resident passed away recently, but LPAs observed no resident file that was available.

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 with care staff. Appeal right handed along with 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: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 08/19/2022 01:55 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: FOOTPRINT CARE HOME	FACILITY NUMBER: 015601366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic 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 operable fire alarms in the facility, which poses an immediate health and safety rights risk to persons in care.
	POC Due Date: 08/20/2022
	Plan of Correction
1 2 3 4	Administrator agrees to fix and install new batteries in the fire alarm and to submit a voice recording for 2 mintues 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: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 08/19/2022 01:55 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: FOOTPRINT CARE HOME	FACILITY NUMBER: 015601366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87405(a)(3)

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not keeping the files of a resident who passes away in the facility available, which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	Licensee agrees to keep all files available in the facility and to submit a self-certification to CCL by POC due date.

Type B

Section Cited

CCR

87506(b)(13)

87506 Resident Records: (b) Each resident’s record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the residents’ ability to function or needed services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the licensee did not comply with the section cited above by not updating progess notes for R1 in his file, which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	Licensee agrees to update progess notes for all residents in the future and to submit a self-certification 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: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC809 (FAS) - (06/04)

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