071441125-10-12-2023-15-AS-AGOZ-CWJSMV-20231012140036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 071441125
Report Date: 10/12/2023
Date Signed: 10/12/2023 02:00:44 PM

Document Has Been Signed on 10/12/2023 02:00 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	CASA BLANCA RETIREMENT HOMES		FACILITY NUMBER:	071441125
ADMINISTRATOR:	SHEILA V MELECION		FACILITY TYPE:	740
ADDRESS:	1055 INA DRIVE		TELEPHONE:	(925) 838-2523
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	18	CENSUS: 11	DATE:	10/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Shelia Melencion, Adminsitrator		TIME COMPLETED:	02:20 PM

NARRATIVE

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Licensing Program Analysts (LPAs) A. Gomez and K. Nguyen conducted an unannounced 1-year Required visit on this date. LPAs met and toured with Administrator, Sheila Melencion. The Administrator currently holds a certificate (#602427740) that expires on 5/11/2023 and is currently in process of receiving new certificate. The facility’s fire clearance was approved for a capacity of 18 which 16 may be non-ambulatory and subject to five (5) hospice waivers.

LPAs toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPAs observed lighting in all rooms that are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 2-day of perishable foods and a minimum 7-day non-perishable foods.

Report continues on 809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CASA BLANCA RETIREMENT HOMES	FACILITY NUMBER: 071441125
	VISIT DATE: 10/12/2023

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Smoke detectors and carbon monoxide were in operating condition during visit. LPAs observed sprinklers throughout the facility. Fire extinguisher was last serviced on January 25, 2022 Fire Drill was last conducted on January 8, 2022. First aid kit was observed to be complete.

LPAs reviewed 3 staff records and staff have criminal record clearance and are associated to the facility. 3 of 3 have current first aid training. LPAs reviewed 4 residents’ records.

The following deficiencies were observed:

1:00pm LPA's observed the MAR to be incomplete and not up to date.

LPA requested the following documents to be submitted to CCLD by 10/21/2023.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2023 02:00 PM - 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CASA BLANCA RETIREMENT HOMES	FACILITY NUMBER: 071441125
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)(3)

This requirement is not met as evidenced by: (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining residence current MAR which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Administrator agrees to submit photographic proof of completed MARs to CCLD by POC date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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