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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441172
Report Date: 05/21/2021
Date Signed: 05/21/2021 03:36:35 PM

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:DANVILLE HOME FOR SENIORSFACILITY NUMBER:
071441172
ADMINISTRATOR:JAQUIAS, AURORA FEFACILITY TYPE:
740
ADDRESS:44 DUBOST COURTTELEPHONE:
(925) 837-5170
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 4DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Aurora Jaquias, Administrator/LicenseeTIME COMPLETED:
01:00 PM
NARRATIVE
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On 5/21/2021 at 9:55am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPA was greeted by Licensee, Aurora Jaquias.

Prior to entry, LPA was requested by Licensee to hand sanitize and LPA's temperature was checked. LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. LPA observed cough etiquette and social distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel and garbage with a lid. Hand washing posters were posted at hand washing stations. The living room and backyard are used as a designated area for visitors.

During record review, LPA observed visitors log and temperature log. LPA observed facility has a copy of Mitigation Plan on file. LPA observed less than 30-day supply of PPE.

The following deficiencies were observed during the visit:
-LPA observed S1 without a mask and S2 had mask pulled down below the chin.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code 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: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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: DANVILLE HOME FOR SENIORS
FACILITY NUMBER: 071441172
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. 2 of 2 staff were not wearing a mask which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2021
Plan of Correction
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Administrator corrected deficiency during visit. LPA observed Administrator and care staff put on the mask. In addition, Administrator agrees to send a copy of training to CCL by 5/27/2021.
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: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021
LIC809 (FAS) - (06/04)
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