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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201069
Report Date: 05/12/2022
Date Signed: 05/13/2022 09:00:31 AM

Document Has Been Signed on 05/13/2022 09:00 AM - 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:GENTLE HEART CARE SERVICES INCFACILITY NUMBER:
019201069
ADMINISTRATOR:SPENCER, ALANNAFACILITY TYPE:
735
ADDRESS:1559 D STREETTELEPHONE:
(510) 342-6740
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Alanna Spencer/AdministratorTIME COMPLETED:
07:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Claudia Martinez ,staff, and informed the purpose of visit. LPA called and spoke with Alanna Spencer, administrator, who authorized Claudia to be with LPA during inspection. Alanna arrived after about 30 minutes.

Facility has LIC808 Mitigation Plan on file.

LPA inspected the living room, dining area, kitchen, bathrooms, bedrooms, laundry area, front and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, surgical masks and no touch temperature probe. Visitor's temperature and symptom checks are done at entry but not recorded. . Residents and staff are screened for COVID-19 symptoms and temperature checked daily but does keep record. Supplies of PPEs checked. Antigen test kits are readily available.

Fire extinguishers checked, observed fully charge with tags showed serviced March 10, 2021. Administrator called provider for schedule of service for extinguishers on this same day. First aid kit was observed complete with manual. Hot water temperature in the bathrooms was tested.


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069
VISIT DATE: 05/12/2022
NARRATIVE
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LPA observed the following:
  • At 3:05 pm, doorbell not working.
  • At 3:08 pm, smoke detector not working.
  • At 3:10 pm, LPA verified and staff, Claudia, stated they don't ask visitors for proof of vaccination. There's also no record of visitor's temperature.
  • At 3:26 pm, Chlorox bleach in unlocked storage.
  • At 3:30 pm, tested water temperature in the bathroom and was measured at 123 degrees Fahrenheit.
  • At 3:31 pm, common towel in the bathroom. There's no paper towel in a dispenser,
  • At 3:32 pm, missing lockset in one of the residents bedrooms and broken blinds in another bedroom.
  • Trash bins in residents bedrooms without lids.
  • No "wear face mask" poster outside the front door.
  • PPEs not sufficient for 30 days for 6 staff. There's only 4 disposable gowns; 16 N95 respirators and no face shields.
LPA verified and administrator stated staff are not fit tested for N95 respirator.

Administrator to submit updated copies of the following documents by May 26, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan

Deficiencies are cited per Title 22 California Code of Regulations on LIC809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with Alanna Spencer.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/13/2022 09:00 AM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/12/2022 at 06:19 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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)(g)
(80087 Buildings 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.
Based on observation, the licensee did not comply with the section cited above. LPA observed Clorox bleach unlocked in storage which poses immediate risk to persons in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above. LPA observed Clorox bleach in unlocked storage which poses an immediate safety risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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4
Staff locked the storage.
In addition, administrator to do in-service training and submit proof by 5/13/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 05/13/2022 09:00 AM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/12/2022 at 06:24 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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087 Buildings 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. LPA observed the following which pose potential safety and personal right risks to persons in care: smoke detector and doorbell not working; broken blinds in the resident's bedroom; missing lockset on other resident's bedroom door
POC Due Date: 05/26/2022
Plan of Correction
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Staff replaced the battery of the smoke detector while LPA is at the facility.
Administrator stated she'll do the following: Proof to be submitted by 5/26/2022:
1. Replace the doorbell and blinds.
2. Install lockset on the bedroom door.
Type B
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, 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, Hot water temperature in the bathroom was tested and measured at 123 degrees Fahrenheit which poses a potential safety risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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Staff adjusted the water temperature to 120 degrees Fahrenheit.
In addtion, administrator to in-service staff and ensure temperature is kept within Regulations range. Proof to be submitted by 5/26/2022.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2022 09:00 AM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/12/2022 at 06:35 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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)(B)
85088 Fixtures, Furniture, Equipment and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.
(4) (B) The use of common towels and washcloths shall be prohibited.

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. LPA observed common hand towel in the bathoom which poses health and personal righta risks to persons in care,
POC Due Date: 05/26/2022
Plan of Correction
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Administrator to install paper towel dispenser and ensure provision of paper towel. Proof to be submitted by 5/26/2022.
Section Cited
Deficient Practice Statement
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3
4
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


LIC809 (FAS) - (06/04)
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