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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
071441172
Report Date:
03/13/2025
Date Signed:
03/13/2025 12:23:59 PM
Document Has Been Signed on
03/13/2025 12:23 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:
DANVILLE HOME FOR SENIORS
FACILITY NUMBER:
071441172
ADMINISTRATOR/
DIRECTOR:
JAQUIAS, AURORA FE
FACILITY TYPE:
740
ADDRESS:
44 DUBOST COURT
TELEPHONE:
(925) 837-5170
CITY:
DANVILLE
STATE:
CA
ZIP CODE:
94526
CAPACITY:
6
CENSUS:
5
DATE:
03/13/2025
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:
Licensee, Aurora Fe Jaquias
TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 3/13/2025 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee, Aurora Fe Jaquias and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory with a hospice waiver for 4.
LPA toured facility with Licensee including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms 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 one week supply of nonperishable and 2-day of perishable foods.
Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 2/26/2025. Emergency Disaster Plan not available. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/10/2025.
At 9:30AM, LPA reviewed 5 of 5 residents records. At 10:10pm, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.
REPORT CONTINUES LIC809-C.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Alona Gomez
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/13/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
5
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:
DANVILLE HOME FOR SENIORS
FACILITY NUMBER:
071441172
VISIT DATE:
03/13/2025
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
LPA observed a male working at the facility who is not associated or cleared in Guardian Immediate $500 Civil Penalty
Facility does not have an available emergency disaster plan
LPA observed unlocked medications in the refrigerator
LPA observed PUB475 poster is not posted correctly and is too small
LPA observed that facility does not have required oxygen signs posted
*** Civil Penalties in the amount of $500 were assessed on todays date***
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/25/2025:
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
Change of Administrator Documents
Current Administrator’s Certificate
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Alona Gomez
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/13/2025
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
03/13/2025 12:23 PM
- It Cannot Be Edited
Created By:
Alona Gomez
On
03/13/2025
at
12:02 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:
DANVILLE HOME FOR SENIORS
FACILITY NUMBER:
071441172
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/13/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having an unassociated and non fingerprint cleared indiviual working at the facility which poses an immediate safety risk to persons in care.
POC Due Date:
03/13/2025
Plan of Correction
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2
3
4
Individual left the facility durring inspection POC clear.
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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2
3
4
Based on observation, the licensee did not comply with the section cited above in having unlocked medivation in the refridgerator which poses an immediate safety risk to persons in care.
POC Due Date:
03/13/2025
Plan of Correction
1
2
3
4
Licensee locked away medicine POC clear
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:
Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE:
03/13/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/13/2025
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
03/13/2025 12:23 PM
- It Cannot Be Edited
Created By:
Alona Gomez
On
03/13/2025
at
12:02 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:
DANVILLE HOME FOR SENIORS
FACILITY NUMBER:
071441172
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/13/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in not having sinage posted in compliance with regulation which poses a potential personal rights risk to persons in care.
POC Due Date:
03/20/2025
Plan of Correction
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By POC Licensee agrees to obtain and post the signage according to regulation standards and notify CCLD
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:
Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE:
03/13/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/13/2025
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
03/13/2025 12:23 PM
- It Cannot Be Edited
Created By:
Alona Gomez
On
03/13/2025
at
12:02 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:
DANVILLE HOME FOR SENIORS
FACILITY NUMBER:
071441172
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/13/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in not having an available emergency disaster plan which poses a potential health and safety risk to persons in care.
POC Due Date:
03/20/2025
Plan of Correction
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2
3
4
By POC Licensee agrees to develop and send a copy of emergency disaster plan to CCLD
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in not having required oxygen signage posted which posed a potential safety risk to persons in care.
POC Due Date:
03/13/2025
Plan of Correction
1
2
3
4
Signage posted POC cleared
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:
Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE:
03/13/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/13/2025
LIC809
(FAS) - (06/04)
Page:
5
of
5