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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201129
Report Date: 11/03/2022
Date Signed: 11/03/2022 12:01:54 PM

Document Has Been Signed on 11/03/2022 12:01 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CONNECTED LIVING OAKLANDFACILITY NUMBER:
019201129
ADMINISTRATOR:TRAIL, SARAFACILITY TYPE:
740
ADDRESS:1724 FILBERT STTELEPHONE:
(925) 826-6830
CITY:OAKLANDSTATE: CAZIP CODE:
94607
CAPACITY: 3CENSUS: 1DATE:
11/03/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Richard Felix, StaffTIME COMPLETED:
12:15 PM
NARRATIVE
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On 11/3/2022 starting at 9:00 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct a post-Licensing Inspection after facility accepted the 1st resident in October 2022. LPA met with Administrator and staff and disclosed the purpose of the visit. Administrator was not available and authorized staff to sign on the report.

During the inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, kitchen, common areas, and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Infection Control Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors.
THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· Approximately 9:20 a.m., LPA observed 10 knives and 1 scissor in the kitchen drawer without being locked. Staff locked them up during visit.
· Approximately 9:30 a.m., LPA observed water temperature was 137.2 degree F.
· Approximately 9:40 a.m., LPA observed the fire extinguisher was last purchased on 8/1/2021.
· Approximately 9:45 a.m., LPA observed gardening tool, paint, and gardening chemical supplies located in the backyard were observed unlocked. Staff locked all items during visit.
· Approximately 10:00 a.m., based on record review, LPA observed that there has no Physician's Report, Pre-Admission Appraisal, and Admission Agreement on resident's file.
The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with staff. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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 11/03/2022 12:01 PM - It Cannot Be Edited


Created By: Catherine Lin On 11/03/2022 at 10:51 AM
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: CONNECTED LIVING OAKLAND
FACILITY NUMBER: 019201129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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, 10 knives and 1 scissor in the kitchen were unlocked, gardening tool, paint and gardening chemical supply in the backyard were unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Staff locked up all items during inspection.
Administrator will provide in-services training to staff and provide training record with staff signatures to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/03/2022 12:01 PM - It Cannot Be Edited


Created By: Catherine Lin On 11/03/2022 at 10:51 AM
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: CONNECTED LIVING OAKLAND
FACILITY NUMBER: 019201129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 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 water temperature was 137.2 degree F which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Administrator will adjust water temperature to meet requirement of regulation and notify CCL by the POC due date.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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 fire extinguisher in the hallway was last purchased on 8/1/2022 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Administrator will purchase new fire extinguisher and maintain renewal yearly, and submit a copy of a purchase receipt to CCL by the POC due date.
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:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2022 12:01 PM - It Cannot Be Edited


Created By: Catherine Lin On 11/03/2022 at 11:21 AM
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: CONNECTED LIVING OAKLAND
FACILITY NUMBER: 019201129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, there is no complete LIC602 on resident's file which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Administrator will provide a copy of complete LIC602 to CCL by the POC due date.
In addition, Administrator will update resident's LIC602 and provide a copy to CCL by 11/23/2022.
Type B
Section Cited
CCR
87457(a)
87457 Pre-Admission Appraisal - General
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, there is no pre-admission appraisal on resident's file which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Administrator will complete the appraisal and provide a copy to CCL by the POC due date.
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:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


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Document Has Been Signed on 11/03/2022 12:01 PM - It Cannot Be Edited


Created By: Catherine Lin On 11/03/2022 at 11:30 AM
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: CONNECTED LIVING OAKLAND
FACILITY NUMBER: 019201129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(a)
87507 Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, there is no Admission Agreement on resident's file which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Administrator will complete the Admission Agreement and provide a copy to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


LIC809 (FAS) - (06/04)
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