<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019200331
Report Date:
08/15/2023
Date Signed:
08/15/2023 12:57:10 PM
Document Has Been Signed on
08/15/2023 12:57 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:
COVENTRY CARE HOME
FACILITY NUMBER:
019200331
ADMINISTRATOR:
MARIDEL Q. CORTEZ
FACILITY TYPE:
735
ADDRESS:
4284 COVENTRY WAY
TELEPHONE:
(510) 972-0861
CITY:
UNION CITY
STATE:
CA
ZIP CODE:
94587
CAPACITY:
6
CENSUS:
3
DATE:
08/15/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:25 AM
MET WITH:
Ricardo Cortez
TIME COMPLETED:
01:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day at around 9:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA was met by staff Ricardo Cortez. LPA explained to Cortez the purpose of the visit. Administrator Maridel Cortez arrived at the facility at a later time but needed to take one client to the doctor's office. The two other clients were in their respective day programs.
The facility has an approved fire clearance for 6 ambulatory clients. It is vendored by the Regional Center of the East Bay (RCEB) as a Level 3 home.
LPA inspected the facility inside and out including but not limited to 3 client rooms and 2 staff rooms. Hot water in the kitchen measured at 122.5 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. Chemicals and cleaning products were observed locked separately from the foods. Fire extinguisher in the kitchen was observed full and has a purchase date of 12/15/2022. Facility has sufficient lightings, furniture and fixtures. There was ample supply of bed sheets, warm blankets, towels and hygiene products. Carbon monoxide and smoke detectors were tested and observed operational. First aid kit was observed complete.
Last fire and earthquake drill was conducted on August 8, 2023. At 9:55 am, LPA reviewed P&I money and log. At 10:10 am, LPA reviewed 3 client files and 3 staff files.
The following deficiencies were observed:
facility does not have an approved infection control plan
hot water measured at 122.5 Fahrenheit
window screens in Room 1 and living room were observed with holes
***continuation on Lic 809C***
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/15/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/15/2023
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
Document Has Been Signed on
08/15/2023 12:57 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
08/15/2023
at
12:13 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:
COVENTRY CARE HOME
FACILITY NUMBER:
019200331
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above in not having an approved infection control plan which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
1
2
3
4
Administrator will submit infection control plan by POC date.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having hot water measure at 122.5 Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/15/2023
Plan of Correction
1
2
3
4
Staff adjusted hot water to 111 Fahrenheit during the visit. Deficiency is cleared.
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:
08/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/15/2023
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
08/15/2023 12:57 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
08/15/2023
at
12:13 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:
COVENTRY CARE HOME
FACILITY NUMBER:
019200331
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in failing to maintain window screens in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/25/2023
Plan of Correction
1
2
3
4
By POC date, Administrator will replace all window screens with holes, take pictures and send to CCL.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
08/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/15/2023
LIC809
(FAS) - (06/04)
Page:
3
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:
COVENTRY CARE HOME
FACILITY NUMBER:
019200331
VISIT DATE:
08/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
At around 11 am, LPA interviewed two staff and one client. The other two clients were in their day programs.
LPA requested the following records to be submitted to CCL by Friday, 8/18/2023:
surety bond
Lic 500
Roster of Residents
Registration, insurance and driver's license
Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809C).
Exit interview was conducted with Ricardo Cortez. Appeal Rights was provided.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/15/2023
LIC809
(FAS) - (06/04)
Page:
5
of
5