015601425-12-17-2024-15-AS-PMAO-DC32JQ-20241217162643

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601425
Report Date: 12/17/2024
Date Signed: 12/17/2024 04:26:52 PM

Document Has Been Signed on 12/17/2024 04:26 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	HEATHER'S CARE HOME		FACILITY NUMBER:	015601425
ADMINISTRATOR/ DIRECTOR:	VEGA-CAJUCOM, MICHELLE M		FACILITY TYPE:	740
ADDRESS:	3279 LANGHORN DRIVE		TELEPHONE:	(510) 648-2461
CITY:	FREMONT	STATE: CA	ZIP CODE:	94555
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:30 PM
MET WITH:	Michelle Vega-Cajucom, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:40 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 12/17/2024 at 2:30 PM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Direct Care Staff, Bernadeth Relon, who phoned the Administrator and explained the purpose of the visit. Administrator certificate is current, Administrator # is 7002125740. The facility’s fire clearance was approved for all six (6) may be non-ambulatory and two (2) hospice waiver. LPAs toured facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 115.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/10/2024. First aid kit was observed to be complete. Earthquake drill was last conducted on 11/09/2024. Fire drill was last conducted on 05/04/2024. At 2:42 PM, LPAs reviewed 5 clients and 4 staff records. LPAs reviewed client's P & I money with logs. The facility has surety bond sufficient to cover amount of cash being handled. At 03:02 PM, LPAs reviewed 4 staff records and 4 of 4 have current first aid training and all 4 are associated to the facility. At 3:20 PM, LPAs reviewed resident’s medications. All records were observed to be complete and up to date. Continue to LIC809-C...

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEATHER'S CARE HOME	FACILITY NUMBER: 015601425
	VISIT DATE: 12/17/2024

NARRATIVE

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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/26/2024:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT:

At 2:30 PM, LPAs observed garden tools such as rake, spade, and etc., unlocked in the backyard.

The Facility was 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 Administrator. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia Manalo	TELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/17/2024 04:26 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEATHER'S CARE HOME	FACILITY NUMBER: 015601425
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 in having garden tools in the backyard unlocked and accesible to residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	The Administrator agrees to place the garden tools in a locked shed and send proof to CCLD by POC 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.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

LIC809 (FAS) - (06/04)

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