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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200272
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:16:35 PM

Document Has Been Signed on 03/16/2022 01:16 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:BIRCHWOOD CARE HOMEFACILITY NUMBER:
019200272
ADMINISTRATOR:MILLICENT DIZONFACILITY TYPE:
735
ADDRESS:4512 BIRCHWOOD COURTTELEPHONE:
(510) 501-5583
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maria Theresa Ordiniza, backup Administrator
Millicent Dizon- Administrator 		TIME COMPLETED:
01:40 PM
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On 3/16/2022, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Maria Theresa Ordiniza. LPA called Administrator . LPA observed 4 clients during the visit. Facility has a completed mitigation plan. Administrator arrived around 11:35AM.

LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

LPA toured facility including but not limited to the bedrooms, bathrooms, dining area, living room, kitchen, garage, and outdoor area. Comfortable room temperature was maintained at 68 degrees Fahrenheit (F). Hot water temperature was measured at 119 degrees Fahrenheit (F) in the hallway bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. LPA observed medications were locked in kitchen cabinet. Carbon monoxide and smoke detectors were observed operational.. Fire extinguisher was observed to be full and last serviced on June 2021. Hygiene items were observed in the garage cabinet. Extra linens and towels were observed in hallway closet. There are no accessible bodies of water observed. Infection control designated leader is the Administrator.

Continued on next page LIC 809-C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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 03/16/2022 01:16 PM - It Cannot Be Edited


Created By: Leslie Ibo On 03/16/2022 at 12:28 PM
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: BIRCHWOOD CARE HOME
FACILITY NUMBER: 019200272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022

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 in C5’s drawers in in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
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Administrator has agreed to replace the C5's drawers, a proof of correction need to be send to CCL by POC date.
Type B
Section Cited
CCR
80077.4(b)(4)
Care for Clients with Incontinence
(b) If a licensee accepts or retains a client who has bowel and/or bladder incontinence, the licensee is responsible for all of the following: (4) Ensuring that clients with incontinence are kept clean and dry, and that the facility remains free of odors.

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 C6's room has an intense smell of urine which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
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Administrator shall clean C6's room and get rid of the odor. Administrator shall also have a sit-down meeting with the resident and case manager, Administrator shall provide a written letter to let LPA know that the situation has been taken care of and the meeting was already conducted with the resident (by POC due date).
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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022


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: BIRCHWOOD CARE HOME
FACILITY NUMBER: 019200272
VISIT DATE: 03/16/2022
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LPA observed the following:

· Facility DOES NOT document daily COVID-19 symptom checks, and any change in condition for staff and residents- Technical assistance provided.

· Facility DO NOT have adequate 30-day supply of PPE (e.g., face masks, respirators, gowns, gloves, and eye protection such as face shield or goggles). Proof of correction needed by 3/25/2022. technical assistance provided.

· No sign-in policy has been enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing). Technical assistance provided.



· Licensee has NOT provided staff with fit testing for N95 respirators, Administrator stated that she will provide N95 Fit testing for all her staff by 3/25/2022. - Technical assistance provided.

· At 10:45AM LPA observed strong urine smell in C6's room, LPA informed the staff about the observation, staff stated that it’s C5’s incontinence products are was left in the room.

· C5’s drawer is not in good repair.

· Bathrooms do not have trash bin with lid, administrator stated that she will buy new one. -Technical assistance provided.



· Staff need PPE donning/doffing training, Administrator agreed to send proof of training by 3/25/2022. - Technical assistance provided.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Millicent Dizon.
Exit interview conducted and appeal rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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