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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441114
Report Date: 09/18/2024
Date Signed: 09/30/2024 04:18:49 PM

Document Has Been Signed on 09/30/2024 04:18 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:MITCHELL HOMEFACILITY NUMBER:
071441114
ADMINISTRATOR/
DIRECTOR:		CECILIA T. DE LEONFACILITY TYPE:
735
ADDRESS:1092 MITCHELL WAYTELEPHONE:
(510) 223-6970
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 6CENSUS: 3DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Pablo De Leon, Care StaffTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 09/18/24 attempted visit. On 09/30/24 around 09:30 AM, Licensing Program Analysts (LPA) L. Holmes and P. Manalo arrived unannounced to conduct a required annual Infection Control Inspection. LPA was greeted by the Care Staff Pablo De Leon.

LPA obtained a resident roster and staff roster. LPA observed hand sanitizer, masks, and COVID-19 signage. LPA toured the facility including, but not limited to common areas, bathrooms, kitchen, garage, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. ADM to post 20 seconds to hand washing sign in the kitchen. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap and garbage cans. Hot water temperature in the shared upstairs residents' bathroom was measured at 106.1 degrees Fahrenheit (F). Fire extinguisher was observed full and last inspected on 06/06/2022 & 06/06/2023. Smoke/Carbon Monoxide detectors were observed operational.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)b
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)

Continued on LIC809...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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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: MITCHELL HOME
FACILITY NUMBER: 071441114
VISIT DATE: 09/18/2024
NARRATIVE
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...continued from LIC809.

The following deficiencies were observed:
-At 10:15 AM: Shovel in front yard, 3 silver trash cans, I blue barrel with bark, 3 weathered brown tarps, a pile of brown landscaping lights, 10-15 wooden boards, milk crate, 4 worn green and blue lawn chairs, broken planter pot, and other random items that were rusted.
-At 10:35 AM: S1 tested heater, not working; providing space heaters.
-At 10:37 AM: Sharps unlocked in the kitchen, laundry detergent on the kitchen floor unlocked.
-At 10:45 AM: Refrigerator and freezer has food spills, 7-10 containers of food without labels, unlocked Pepto Bismol and Day Quil.
-At 10:50 AM: Vitamins, allergy medication, prescription medication in common room unlocked.
-At 10:55 AM: Two fire extinguishers expired 06/06/2022 & 2023.
-At 10:45 AM: No running water in downstairs bathroom.
-At 02:01 PM: Personnel records did not include all CPR/1st Aid and all LIC501s.

Based on observation, deficiencies are cited from Title 22 California Code of Regulations and listed on LIC 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided to Care Staff, Pablo De Leon.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/30/2024 04:18 PM - It Cannot Be Edited


Created By: Lisha Holmes On 09/30/2024 at 02:26 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: MITCHELL HOME
FACILITY NUMBER: 071441114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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4
Based on observation, interview, and record reviews the licensee did not comply with the section cited above by having debris items in the front and backyard, refrigerator unsanitary, expired fire extinguishers, unlocked sharps, detergent and medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2024
Plan of Correction
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Licensee will send photos of the new fire extinguishers by 10/01/24, front and backyard photos by 11/01/24, sharps locked during visit by S1, medication and detergent locked during visit by S1. Licensee to self-certify that all staff have reviewed regulations.
Type A
Section Cited
CCR
80088(e)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

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 in 1 out of 2 bathrooms not delivering hot water which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Care Staff sent video of faucet delivering water from downstairs bathroom. Licensee to self-certify that all staff have reviewed regulations.
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:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/30/2024 04:18 PM - It Cannot Be Edited


Created By: Lisha Holmes On 09/30/2024 at 02:26 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: MITCHELL HOME
FACILITY NUMBER: 071441114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record reviewed, the licensee did not comply with the section cited above in 1 out 2 Care Staff no having complete personel records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
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Licensee to self-certify that all staff have reviewed regulations, complete personnel files and provide proof to CCLD by POC date.
Type B
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 1 out of 1 count where detergent was left on the kitchen floor which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Licensee to self-certify that all staff have reviewed regulations. Detergent was locked during the visit by S1.
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:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/30/2024 04:18 PM - It Cannot Be Edited


Created By: Lisha Holmes On 09/30/2024 at 02:26 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: MITCHELL HOME
FACILITY NUMBER: 071441114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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, interview, the licensee did not comply with the section cited above by having unlocked medications in the common area and refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Licensee to self-certify that all staff have reviewed regulations, S1 locked medications during visit.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
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