<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200515
Report Date: 09/15/2023
Date Signed: 09/15/2023 04:30:39 PM

Document Has Been Signed on 09/15/2023 04:30 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:
09/15/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:James Santos, Administrator
Carlota Moises, Caregiver		TIME COMPLETED:
04:45 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 9/15/2023 at 12:40PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Caregiver, Carlota Moises and explained the purpose of the visit. Administrator, James Santos arrived 2 hours later.

During visit, LPA reviewed staff training and observed staff completed training which includes dementia, emergency, medication, hospice, ADL (Activities of Daily Living) care, and other topics. At around 2:20PM, LPA reviewed a sample of resident's medications. LPA interviewed 2 residents and 2 staff starting at 3:00PM.

At 2:40PM, LPA observed R1 has a doctor's order for Cholecalciferol and Ferrous Sulfate. However, facility did not obtain the supplements and have not been giving the supplements to R1. Additionally, facility have been giving Multi-vitamins to R1 when there was a discontinued order on 4/11/2023.

At 2:50PM, LPA observed centrally stored records have not been updated for R1.

At 3:00PM, LPA was informed that S1's file is not available for review.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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 3
Document Has Been Signed on 09/15/2023 04:30 PM - It Cannot Be Edited


Created By: Grace Luk On 09/15/2023 at 04:00 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: ABIGAIL'S GUEST HOME
FACILITY NUMBER: 019200515

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not following doctor's order regarding three of R1's medications which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/18/2023
Plan of Correction
1
2
3
4
Administrator has agreed to obtain Cholecalciferol and Ferrous Sulfate supplements for R1. Additionally, Administrator as agreed to stop R1's multi-vitamin until another doctor's order is obtained. Administrator will submit picture of supplements and doctor's order/self-certification to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/15/2023 04:30 PM - It Cannot Be Edited


Created By: Grace Luk On 09/15/2023 at 04:08 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: ABIGAIL'S GUEST HOME
FACILITY NUMBER: 019200515

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
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 by not updating centrally stored records which poses a potential health and safety risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
1
2
3
4
Administrator has agreed to update centrally stored records for R1 and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
87412(f)
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
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 by not having S1's file at the facility during inspection which poses a potential health and safety risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
1
2
3
4
Administrator has agreed to submit S1's file (LIC503, LIC501, TB test, First Aid training, LIC508) to CCLD by POC date.

Civil penalty of $250 is being assessed for a repeat violation.
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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3