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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200515
Report Date: 10/14/2022
Date Signed: 10/14/2022 12:15:28 PM


Document Has Been Signed on 10/14/2022 12:15 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: 4DATE:
10/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Aurelia Mendoza, Administrator
Carlota Moises, Caregiver		TIME COMPLETED:
12:30 PM
NARRATIVE
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On 10/14/2022 at 11:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with caregiver, Carlota Moises. Administrator, Aurelia Mendoza arrived about 30 minutes later.

During a complaint investigation (15-AS-20210610100816), LPA observed the following deficiency.

LPA observed facility did not submit incident report when R1 went to the hospital on 6/6/2021. Also, when R1 passed away on 6/26/2022, LPA did not receive death report for R1.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency 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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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 10/14/2022 12:15 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: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited

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Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events... This requirement is not met as evidence by:
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Based on investigation, licensee did not comply with the section cited above by not meeting reporting requirements which poses a potential health and safety risk to the persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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