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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601411
Report Date: 04/29/2022
Date Signed: 04/29/2022 12:22:45 PM


Document Has Been Signed on 04/29/2022 12:22 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:WELCOME HOME SENIOR RESIDENCE (PLEASANTON)FACILITY NUMBER:
015601411
ADMINISTRATOR:VELASCO,J & CHOU, SFACILITY TYPE:
740
ADDRESS:6839 SINGLETREE COURTTELEPHONE:
(510) 685-8388
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:6CENSUS: DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Julita Velasco, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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On 4/29/22 at 9:50am, Licensing Program Analysts (LPAs) K.Nguyen, and L. Francisco arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Julita Velasco, and explained the purpose of the visit. Licensee, Steve Chou later arrived at 11:25 AM.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. Hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has an adequate 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.

The following deficiency was observed during visit:
-At 10:20 AM, LPAs observed an office and staff room added in the garage. No records of building permit on file.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalty.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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 04/29/2022 12:22 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: WELCOME HOME SENIOR RESIDENCE (PLEASANTON)
FACILITY NUMBER: 015601411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Facility failed to obtain a building permit for office and staff room located in the garage which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2022
Plan of Correction
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Administrator will obtain a building permit and submit a copy of approval and LIC 200 to CCL or remove staff room and office 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
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