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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200900
Report Date: 05/13/2022
Date Signed: 05/13/2022 03:30:34 PM

Document Has Been Signed on 05/13/2022 03:30 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:AMADORFACILITY NUMBER:
019200900
ADMINISTRATOR:TANYA M BARRETOFACILITY TYPE:
735
ADDRESS:7137 AMADOR VALLEY BLVDTELEPHONE:
(925) 248-2148
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 4CENSUS: 3DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Sabrina Balal, DSPTIME COMPLETED:
03:45 PM
NARRATIVE
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On 5/13/22 at 1:50 PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Francisco arrived unannounced to conduct Infection Control Inspection. LPAs met with Direct Support Professional (DSP), Sabrina Balal and explained the purpose of the visit. Administrator was not available during the visit. Administrator gave verbal permission for LPAs to deliver the report to DSP Sabrina.

During the Infection Control Inspection, LPAs toured facility with DSP including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. 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, thermometer and hand sanitizer were observed at screening station. 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 DEFICIENCIES WERE OBSERVED:

· At 2:10 PM, LPAs observed the padlock attached on the centrally stored medication cabinet was not properly locked. Deficiency cleared during visit. LPAs observed staff locked the centrally stored medication.
· At 2:40 PM during record review, LPAs were unable to review staff 1 (S1)’s file because staff did not have access to the server (Paylocity) which is used to maintain staff records.


REPORT CONTINUES ON 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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 05/13/2022 03:30 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/13/2022 at 02:45 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: AMADOR
FACILITY NUMBER: 019200900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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2
3
4
Based on LPAs observation the licensee did not comply with the section cited above. LPAs observed the padlock attached on the centrally stored medication cabinet was not properly locked which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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2
3
4
Deficiency cleared during visit. LPAs observed staff locked the centrally stored medication.

In addition, Administrator will review regulation and conduct in-service training with staff, and submit a copy of training agenda with staff signature by 5/20/2022.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


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: AMADOR
FACILITY NUMBER: 019200900
VISIT DATE: 05/13/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/20/2022:

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

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/13/2022 03:30 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/13/2022 at 03:05 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: AMADOR
FACILITY NUMBER: 019200900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
PERSONNEL RECORDS
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPAs were unable to review S1's records because staff did not have access to the server (Paylocity) which is used to maintain staff records which poses a potential health or safety risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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By POC date, Adminstrator will review regulation and submit a copy of plan to CCL ensuring records are accessble for review by Licensing.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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