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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200812
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:46:22 PM

Document Has Been Signed on 07/26/2023 03:46 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:PELICAN HILL CARE HOMEFACILITY NUMBER:
019200812
ADMINISTRATOR:ALBERS, THERAFACILITY TYPE:
735
ADDRESS:2824 PELICAN DRTELEPHONE:
(510) 477-0444
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Thera Albers, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On this day at around 9:35 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Eufrocina Hernandez. LPA explained to Hernandez the purpose of the visit. Administrator Thera Albers arrived at the facility at a later time. The facility is a Level 4C home vendorized by the Regional Center of the East Bay (RCEB).

Upon arrival, LPA observed Client 1 (C1) sitting in one of the chairs with a gait belt placed across C1. LPA also observed C1 with a bruise on the neck. Hernandez states C1 fell from the chair few days ago and got the bruise from the fall.

LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen, dining area, backyard and living area. There was sufficient lighting throughout the facility. No bodies of water were observed. There was sufficient supply of perishable and non-perishable foods. Sufficient blankets, sheets, towels, hand towels were observed. Fire extinguisher in the kitchen area was observed to be full and last inspected on 11/7/2022. First aid kit was observed complete and updated. Smoke detector and carbon monoxide were tested and observed operational.

Last fire and earthquake drills were done on 7/15/2023.

At around 10:10 am, LPA reviewed 5 client files and 4 staff files. At 12:30 pm, LPA reviewed P&I money and log with Administrator.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PELICAN HILL CARE HOME
FACILITY NUMBER: 019200812
VISIT DATE: 07/26/2023
NARRATIVE
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The following deficiencies were observed:
  • at around 9:45 am, LPA observed different medications unlocked in a drawer in the kitchen
  • at around 9:48 am, LPA observed cleaning chemical unlocked in the common bathroom
  • at around 10:01 am, LPA observed hot water measured at 140 degrees Fahrenheit
  • at around 12:39 pm, LPA observed surety bond is not sufficient to cover amount of cash being handled at one time


Deficiencies were cited per Title 22 California Code of Regulations. Please refer to Lic 809D.

Exit interview was conducted and Appeal Rights was provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 07/26/2023 03:46 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/26/2023 at 02:27 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: PELICAN HILL CARE HOME
FACILITY NUMBER: 019200812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in having cleaning chemical unlocked in one of the drawers in the common bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Staff locked cleaning chemical during the visit.
Type A
Section Cited
CCR
80072(a)(8)(A)
Personal Rights
(A) Postural supports shall be limited to appliances or devices including braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a client's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a client from falling out of bet [sic.], a chair, etc.

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 in having C1 restrained with a gait belt while sitting in the chair without an approved exception which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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By POC date, Administrator will submit request for exception to use gait belt for Client 1.
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-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


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Document Has Been Signed on 07/26/2023 03:46 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/26/2023 at 02:27 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: PELICAN HILL CARE HOME
FACILITY NUMBER: 019200812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(2)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (2) Facility staff, except those authorized by law, shall not administer injections but staff designated by the licensee shall be authorized to assist clients with self-administration of injections as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in having staff inject client with Insulin since 7/10/2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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By POC date, Administrator will contact Home Health to manage insulin of Client and notify LPA.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observaiton, the licensee did not comply with the section cited above in having medications left unlocked in one of the drawers in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Staff locked away medications during the visit. Deficiency is cleared.
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-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2023 03:46 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/26/2023 at 02:27 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: PELICAN HILL CARE HOME
FACILITY NUMBER: 019200812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80092(b)(5)
Restricted Health Conditions
(b) Care for the following health conditions must be provided only as specified in Sections 80092.1 through 80092.11. (5) Insulin-dependent Diabetes as specified in Section 80092.8.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review codncuted, the licensee did not comply with the section cited above in having one of the staff inject client 1 with Insulin since 7/10/2023 without an approved exception which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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By POC date, Home Health will be contacted to administer insulin to client 1.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 07/26/2023 03:46 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/26/2023 at 02:27 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: PELICAN HILL CARE HOME
FACILITY NUMBER: 019200812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 in having dusts in kitchen cabinets, oven and vents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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By POC date, Administrator will get the kitchen cleaned and vents cleaned. Administrator will notify LPA once completed.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not having a shaded area outside which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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By POC date, Administrator will provide a shaded area in the backyard and notify LPA once completed.
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-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


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