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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200205
Report Date: 03/09/2022
Date Signed: 03/09/2022 10:59:54 AM

Document Has Been Signed on 03/09/2022 10:59 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:HANSEN HOMEFACILITY NUMBER:
019200205
ADMINISTRATOR:JESUSA MANTARINGFACILITY TYPE:
735
ADDRESS:7421 HANSEN DRIVETELEPHONE:
(510) 938-3661
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Orlando FajardoTIME COMPLETED:
11:10 AM
NARRATIVE
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On 03/09/22 at 09: 05 am Licensing Program Analysts (LPA) J. Clancy-Czuleger and K. Nguyen arrived unannounced to conduct infection control inspection LPAs meet with Licensee Orlando Fajardo and explained the purpose of the visit.

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. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. 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. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks.

The following deficiency was observed during the visit:

LPAs observed dirty walls, and bathroom


LPAs observed that the facility did not have the LIC 610
LPAs observed that the facility did not have the LIC 9020
LPAs observed chairs blocking the outdoor pathway to emergency exit

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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 03/09/2022 10:59 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 03/09/2022 at 10:28 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: HANSEN HOME
FACILITY NUMBER: 019200205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above that the walls and bathroom was visably dirty which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2022
Plan of Correction
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By POC date, Administrator will submit photos of cleaned walls and bathroom
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a stack of chairs blocking the outdoors emergency exit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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POC cleared durring visit
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/09/2022 10:59 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 03/09/2022 at 10:28 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: HANSEN HOME
FACILITY NUMBER: 019200205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 by not having a copy of the emergency disaster plan (LIC 610) at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2022
Plan of Correction
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By POC date licensee will submit a copy of the plan to licensing
Type B
Section Cited
HSC
1565(a)(4)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (4) A contact information list of all of the following:

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 by not having a copy of the client roster/contacts (LIC 9020) at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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POC cleared durring visit
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022


LIC809 (FAS) - (06/04)
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