019200688-4-29-2022-15-AS-KNGN-CDXVKN-20220429163037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200688
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:30:51 PM

Document Has Been Signed on 04/29/2022 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:	LAKE CHABOT ASSISTED LIVING		FACILITY NUMBER:	019200688
ADMINISTRATOR:	TET, SAMUEL		FACILITY TYPE:	740
ADDRESS:	18821 CARLTON AVE		TELEPHONE:	(888) 818-8101
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	3	CENSUS: 3	DATE:	04/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Samuel Tet, Adminstrator		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 4/29/22 at 3;15pm, Licensing Program Analysts (LPAs) K.Nguyen, and L. Francisco arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Samuel Tet and explained the purpose of the visit. During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, hand washing stations, bedrooms, common areas, and kitchen. 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, and hand sanitizer were observed. 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 DEFICIENCY WAS OBSERVED DURING VISIT -At 3:30 PM, LPAs observed fruit being stored on the same shelf as cleaning supplies. LPAs observed Administrator remove fruit from shelf. Deficiency cleared during visit. REPORT CONTINUES ON 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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 04/29/2022 04:30 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: LAKE CHABOT ASSISTED LIVING	FACILITY NUMBER: 019200688
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(25)

General Food Service Requirements

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed fruits are being stored on the same shelf as cleaning supplies which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/30/2022
	Plan of Correction
1 2 3 4	Deficiency cleared during visit. LPAs observed Administrator remove fruits from the shelf. In addition, Administrator will review regulations and conduct training with staff, and submit a copy of training with staff signatures by 5/6/2022.

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: LAKE CHABOT ASSISTED LIVING	FACILITY NUMBER: 019200688
	VISIT DATE: 04/29/2022

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/13/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

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

Exit interview conducted. Appeal rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

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