019200724-7-17-2024-15-AS-CFOR-D79SNR-20240717140159

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200724
Report Date: 07/17/2024
Date Signed: 07/17/2024 02:02:14 PM

Document Has Been Signed on 07/17/2024 02:02 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:	GRAND LAKE HOME		FACILITY NUMBER:	019200724
ADMINISTRATOR:	KOO, HASMIN B		FACILITY TYPE:	740
ADDRESS:	365 STATEN AVENUE		TELEPHONE:	(510) 893-5308
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	14	CENSUS: 13	DATE:	07/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	MYRNA QUIZON, CAREGIVER		TIME COMPLETED:	02:20 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	Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-year required visit on 7/17/2024 at 9:50am. LPA met and toured with Caregiver, Myrna Quizon. Administrator, Hasmin Koo arrived at 11:00am. The Administrator currently holds a certificate (#7033073740) that expires on 12/23/2025. The facility’s fire clearance was approved for 14 ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 11 total bedrooms which 3 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom were measured at 108.5 and 105 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke detectors and carbon monoxide were not in operating condition during visit. Fire extinguishers were last serviced on 5/21/2024. Emergency Disaster Plan was last posted on 02/15/2024. First aid kit was observed to be complete. LPA reviewed 4 staff files. All files were complete . LPA reviewed 8 resident files and all were found to be complete. Fire drill conducted on 6/24/2024 Report continues on 809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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: GRAND LAKE HOME	FACILITY NUMBER: 019200724
	VISIT DATE: 07/17/2024

NARRATIVE

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CONTINUE FROM LIC 809

LPAs observed the following deficiencies:
- at 3:10 PM. LPA observed a freezer leaking.

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

The following forms to be updated and submitted to CCL by 07/24/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 610E Emergency Disaster Plan

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/17/2024 02:02 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: GRAND LAKE HOME	FACILITY NUMBER: 019200724
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

(a) The facility shall be...in good repair at all times. ...maintenance services and procedures for the safety and well-being of residents... 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 in having the a freezer inoperable which posses a potential health and safety risk for persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to replace freezer and submit a copy of the receipt to the department by the 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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