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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200812
Report Date: 08/29/2024
Date Signed: 08/29/2024 04:14:26 PM

Document Has Been Signed on 08/29/2024 04:14 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/
DIRECTOR:		ALBERS, THERAFACILITY TYPE:
735
ADDRESS:2824 PELICAN DRTELEPHONE:
(510) 477-0444
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Thera AlbersTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On this day at around 10:05 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 and co Administrator Michael Lim 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).

One client and two staff were observed upon LPA arrival. Client was observed doing online zoom classes.

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. Passageways and hallways were observed free of obstruction. 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 11/1/2023. First aid kit was observed complete and updated. Smoke detectors were tested and observed operational. Last fire and earthquake drills were done on 8/10/2024. At around 10:50 am, LPA reviewed 4 client files and 4 staff files. At 12:23 pm, LPA reviewed P&I money and log with Administrator. The facility has sufficient amount of surety bond to cover cash being handled at one time.

The following deficiencies were observed:
  • at around 10:10 am, 8 bottles of Robitussin were observed unlocked in the refrigerator
  • at around 10:13 am, LPA observed hot water measured at 126 degrees Fahrenheit

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: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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Document Has Been Signed on 08/29/2024 04:14 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/29/2024 at 12:39 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: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 hot water measuri at 126 Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Hot water was adjusted within (105-120F) during the visit. This deficiency is cleared.
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 observation, the licensee did not comply with the section cited above in having 8 bottles of Robitussin unlocked in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Staff locked all 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: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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