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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200191
Report Date: 06/10/2022
Date Signed: 06/10/2022 11:19:49 AM

Document Has Been Signed on 06/10/2022 11:19 AM - 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:CEDAR HOME AT NILES GROVEFACILITY NUMBER:
019200191
ADMINISTRATOR:TRAN, MONIQUE NFACILITY TYPE:
735
ADDRESS:35525 NILES BLVD.TELEPHONE:
(510) 818-0716
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Edith, Sarmiento- Administrator TIME COMPLETED:
11:30 AM
NARRATIVE
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On 06/10/2022 at 9:30am, Licensing Program Analysts (LPAs) L. Fici & C. Lin arrived unannounced to conduct an annual Infection Control Inspection. LPAs met with Administrator Edith, and explained the purpose of the visit. Administrator- Monique Tran is out of town. Administrator- Clay Chandreve arrived 13 minutes later and met with LPAs.

LPAs toured facility with ADM, 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. A sign-in policy, Covid questionnaires, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Water temperature was measured at 119.3. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. 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. Fire extinguisher was observed serviced for October 22, 2021. LPA observed facility passages inside and out free of obstruction.

Continue on Lic809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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: CEDAR HOME AT NILES GROVE
FACILITY NUMBER: 019200191
VISIT DATE: 06/10/2022
NARRATIVE
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Continued on Lic809c

The following deficiency was observed:

1. During file review, LPAs observed all 6 residents were over age 60.

The following forms are to be updated and submitted to CCLD By 6/17/2022.

- LIC500- Personnel Report
- LIC308- Designation of Administrative Responsibility
- LIC610E- Emergency Disaster Plan
- An updated copy of Administrator certificate

Exit interview conducted. report provided, alone with appeal rights.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2022 11:19 AM - It Cannot Be Edited


Created By: Liridon Fici On 06/10/2022 at 10:45 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CEDAR HOME AT NILES GROVE
FACILITY NUMBER: 019200191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)

(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having an age exemption approved by CCL since 2019, which posed a potential health and safety risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
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Administrator agrees to submit an age exemption to CCL by POC due 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-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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