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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200254
Report Date: 05/22/2022
Date Signed: 05/22/2022 11:29:34 AM

Document Has Been Signed on 05/22/2022 11:29 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:FAIRFIELDFACILITY NUMBER:
019200254
ADMINISTRATOR:LEEA BURNSFACILITY TYPE:
735
ADDRESS:32724 FAIRFIELD ST.TELEPHONE:
(510) 475-5383
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 4DATE:
05/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Fernando Fernandez, CaregiverTIME COMPLETED:
11:35 AM
NARRATIVE
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On 5/22/2022 at 10:05AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Fernando Fernandez, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Leea Burns and approval was given for Caregiver to sign documents.

Upon entry, LPA's temperature was checked and screening station was observed. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared clients’ bathroom was measured at 100.2 degrees Fahrenheit. Fire extinguisher was last serviced on 7/1/2021.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 5/28/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: FAIRFIELD
FACILITY NUMBER: 019200254
VISIT DATE: 05/22/2022
NARRATIVE
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Continued from LIC809.

-LIC610D Emergency Disaster Plan
- Current Administrator Certificate

The following deficiency were observed:

-At 10:25AM, LPA observed knives in unlocked kitchen cabinet near stove.
-At 10:40AM, LPA observed there was not a 7-day supply of non-perishables and a 2-day of perishables.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/22/2022 11:29 AM - It Cannot Be Edited


Created By: Laura Hall On 05/22/2022 at 11:09 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: FAIRFIELD
FACILITY NUMBER: 019200254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
80087 Buildings and Grounds
g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 in having knives in unlocked cabinet drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2022
Plan of Correction
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Administrator agreed to lock knives to make inaccessible to clients in care. Caregiver locked drawer that contained knives during inspection. Deficiency cleared.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2022 11:29 AM - It Cannot Be Edited


Created By: Laura Hall On 05/22/2022 at 11:12 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: FAIRFIELD
FACILITY NUMBER: 019200254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
85076 Food Service
(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 in not have a 7-day non-perishable and 2-day perishable supply of food which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator agreed to purchase food and submit photo of food and receipt to CCLD 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2022


LIC809 (FAS) - (06/04)
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