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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200346
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:04:19 AM

Document Has Been Signed on 02/17/2022 11:04 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:CALLAHAN HOMEFACILITY NUMBER:
019200346
ADMINISTRATOR:GAIL CALLAHANFACILITY TYPE:
735
ADDRESS:658 VALLE VISTA AVENUETELEPHONE:
(510) 832-4258
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 12CENSUS: 9DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Amanda Callahan, AdministratorTIME COMPLETED:
11:10 AM
NARRATIVE
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On 2/17/2022 starting at 8:40 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Amanda Callahan and disclosed the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors.

THE FOLLOWING DEFICIENCY WAS OBSERVED:
ยท Approximately 9:10 a.m., LPA observed knives drawer in the kitchen was unlocked. Administrator locked it up immediately. However, the lock was installed on the right side of the drawer, the left far side of the drawer was still able to be pulled out 4.5' wide enough to access to knives and scissors; and unlocked gardening tools and constructional power tools were observed in the backyard where was accessible to clients.


The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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 02/17/2022 11:04 AM - It Cannot Be Edited


Created By: Catherine Lin On 02/17/2022 at 10:48 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: CALLAHAN HOME
FACILITY NUMBER: 019200346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above where knives in the kitchen, gardening tools and power tools in the backyard were accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Administrator agreed to fix the knives drawer and remove tools to a locked shed, and submit photos to CCL by POC due 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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
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