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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200515
Report Date: 07/08/2022
Date Signed: 07/08/2022 04:37:10 PM


Document Has Been Signed on 07/08/2022 04:37 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:ABIGAIL'S GUEST HOMEFACILITY NUMBER:
019200515
ADMINISTRATOR:AURELIA MENDOZAFACILITY TYPE:
740
ADDRESS:6372 ARLINGTON DRIVETELEPHONE:
(925) 216-2921
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:6CENSUS: 5DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Carlota Moises, CaregiverTIME COMPLETED:
02:30 PM
NARRATIVE
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On 7/8/2022 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Carlota Moises. LPA spoke with licensee, Aurelia Mendoza on the phone and stated she was unable to be at the facility.

Upon entry, LPA's temperature was checked and asked to fill out the visitor's log. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPA observed cough etiquette, signs & symptoms, and physical distancing posted in the common areas. All bathrooms were equipped with soap and paper towels. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitors log and temperature log for residents and staff. LPA observed facility does have a copy of Mitigation Plan on file. Staff was FIT tested and provided FIT testing completion card. LPA observed PPE, food supplies, and paper supplies are sufficient.

At 12:50PM, LPA observed knives drawer was unlocked and cleaning supply cabinet had a missing lock. Caregiver stated administrator is aware of the missing lock and will be fixed soon. Caregiver locked up the knives drawer during inspection.

At 1:00PM, LPA observed unlocked prescription creams in the hallway bathroom and unlocked medication on the table. Caregiver locked up prescription creams and medication during inspection.

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

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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 2


Document Has Been Signed on 07/08/2022 04:37 PM - It Cannot Be Edited

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: ABIGAIL'S GUEST HOME
FACILITY NUMBER: 019200515

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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, the licensee did not comply with the section cited above by having knives drawer unlocked and a missing lock on the cleaning supply cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/09/2022
Plan of Correction
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Caregiver locked the knives drawer during inspection. Facility has agreed to install a new lock on the cleaning supply cabinet and submit picture proof to CCLD by POC date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 by having unlocked prescription creams in the bathroom and unlocked medication on the table which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/09/2022
Plan of Correction
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Caregiver locked up the prescription creams and medication during inspection.

Deficiency 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
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