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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200673
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:46:10 PM

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:D'NALOR CARE HOMES, LLCFACILITY NUMBER:
019200673
ADMINISTRATOR:WILSON, ROLANDFACILITY TYPE:
740
ADDRESS:2706 106TH AVETELEPHONE:
(510) 756-6122
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY:6CENSUS: 6DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Roland WilsonTIME COMPLETED:
03:00 PM
NARRATIVE
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On 11/29/2021 at 12:37 pm Licensing Program Analysts (LPAs) G. Clark and G Luk arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Roland Wilson and explained 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. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 Failure to correct deficiencies by POC date may result in additional Civil Penalties.

At approximately 12:55 LPAs observed a door chain on the front door. The chain was located at the very top of the door.

Around 1 pm, LPAs toured facility with Administrator, cameras were present in resident rooms, hallways, living room, and kitchen with motion sensors.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
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 4
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: D'NALOR CARE HOMES, LLC
FACILITY NUMBER: 019200673
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(6)

87705 Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents.

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 a door chain on the front door which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/29/2021
Plan of Correction
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Administrator agreed to removed door chain. The chain was removed during the visit. Deficiency was cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date: 11/29/2021
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: D'NALOR CARE HOMES, LLC
FACILITY NUMBER: 019200673
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(1)
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.



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 cameras in the resident bedrooms, and common areas of the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 11/29/2021
Plan of Correction
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Administrator agreed to remove the cameras. Cameras were removed during visit. Deficiency cleared during visit.
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4