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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441125
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:17:16 AM


Document Has Been Signed on 05/20/2022 11:17 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:CASA BLANCA RETIREMENT HOMESFACILITY NUMBER:
071441125
ADMINISTRATOR:SHEILA V MELECIONFACILITY TYPE:
740
ADDRESS:1055 INA DRIVETELEPHONE:
(925) 838-2523
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:18CENSUS: 14DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Sheila Melecion, AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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On 5/20/2022 starting at 9:35 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Sheila Melecion and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility with Administrator 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. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap and paper towel. Facility has a supply of PPEs maintained at central location and easily accessible for staff.

At 10:15 AM, LPAs reviewed 4 staff records and observed 4 of 4 staff have health screening and TB test on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

THE FOLLOWING DEFICIENCY WAS OBSERVED:
-At 9:50 AM, LPAs observed unlocked medications on office table accessible to residents. Deficiency cleared during visit. LPAs observed staff removed medications and locked it away.


REPORT CONTINUES ON 809C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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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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: CASA BLANCA RETIREMENT HOMES
FACILITY NUMBER: 071441125
VISIT DATE: 05/20/2022
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/27/2022:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • Current Administrator’s Certificate


The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/20/2022 11:17 AM - It Cannot Be Edited

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: CASA BLANCA RETIREMENT HOMES
FACILITY NUMBER: 071441125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines 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. LPAs observed unlocked medication on office table accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Deficiency cleared during visit. LPAs observed Administrator remove medication and locked it away.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training with staff signature to CCL by 5/27/2022
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7