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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200272
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:06:53 PM

Document Has Been Signed on 08/03/2023 03:06 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:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Millicent DizonTIME COMPLETED:
03:20 PM
NARRATIVE
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On this day at around 10:05 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Theresa Ordiniza. LPA explained to Ordiniza the purpose of the visit. The facility is a Level 4i home vendored by the Regional Center of the East Bay (RCEB).
Administrator arrived at a later time

LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen, dining area, backyard and living area. There was sufficient lighting throughout the facility. No bodies of water were observed. There was sufficient supply of perishable and non-perishable foods. Sufficient blankets, sheets, towels, hand towels were observed. Fire extinguisher in the kitchen area was observed to be full and last inspected on 6/22/2023. First aid kit was observed complete and updated. Smoke detector and carbon monoxide were tested and observed operational.

Last fire drill was done on July 6, 2023 and last earthquake drill was done on 5/1/2023. At around 11:45 AM, LPA reviewed P&I money and log. The facility has sufficient amount of surety bond to cover amount of money being handled at one time.

At 12 noon, LPA reviewed 5 client files and 5 staff files.

At around 10:40 AM, LPA observed 5 pots of plants on right side passageway and 2 garbage bins on left side passageway.

Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted and Appeal Rights was provided to Theresa Ordiniza who was authorized by Administrator to sign the report.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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 08/03/2023 03:06 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/03/2023 at 02:42 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: 08/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 in having pots and garbage bins on passageways which poses/posed a potential health, safety or personal rights risk to persons. LPA observed 2nd gate does not open easily and has dropped and is hard to open.
POC Due Date: 08/03/2023
Plan of Correction
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Staff removed pots and garbage bins from blocking passageways during the visit.
Administrator states 2nd gate will be removed. Photo proof will be sent to CCL on or before 8/18/2023.
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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023


LIC809 (FAS) - (06/04)
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