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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200717
Report Date: 05/26/2021
Date Signed: 05/26/2021 12:16:23 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:BAY HARBOUR CARE HOMEFACILITY NUMBER:
019200717
ADMINISTRATOR:RIVAS, DANIELAFACILITY TYPE:
740
ADDRESS:510 CENTRAL AVETELEPHONE:
(510) 523-0113
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:12CENSUS: 3DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Bernadette Hunsaker, Care StaffTIME COMPLETED:
12:30 PM
NARRATIVE
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On 5/26/2021 at 9:20am, Licensing Program Analysts (LPAs) L. Francisco and A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPAs met with Care Staff, Bernadette Hunsaker and explained the purpose of the visit.

Upon entry, LPA's temperatures were checked and LPAs observed hand sanitizer and hand washing sign at screening station. LPAs toured facility including but not limited to common areas, hand washing stations, bedrooms, and kitchen. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel and garbage with a lid. Hand washing posters were posted at hand washing stations.

During record review, LPA observed visitors log and temperature log. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-Approximately at 9:25am, symptoms check were not initiated at entrance. LPAs temperature were checked. However, LPAs were not screened for COVID-19 symptoms.
-Approximately at 9:40am, based on interview with staff, surveillance testing is not being completed in accordance to Local Health Order issued on 11/23/2020.

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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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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: BAY HARBOUR CARE HOME
FACILITY NUMBER: 019200717
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, Licensee did not comply with the regulation above. LPAs observed facility did not implement COVID-19 symptom screening upon entry which poses a potential health and safety risk to residents in care.
POC Due Date: 06/04/2021
Plan of Correction
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By POC date, Administrator will provide staff training and implement symptoms check for visitors and send CCL a copy of training.
Type B
Section Cited
CCR
87405(d)(2)
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

(2) Knowledge of and ability to conform to the applicable laws, rules and regulations


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with staff and record review, Licensee did not comply with the regulation cited above. Surveillance testing is not being conducted in accordance to Local Health Order issued on 11/23/2021 which poses a potential health and safety risks to residents in care.
POC Due Date: 06/02/2021
Plan of Correction
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By POC date, Administrator will schedule testing for staff as required by Local County Health Order issued 11/23/2021.
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: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
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