071441217-7-8-2021-15-AS-LHAL-C4QVN7-20210708163440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 071441217
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:35:00 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:	DIVINE'S HOME		FACILITY NUMBER:	071441217
ADMINISTRATOR:	RIFORMO, MARIA		FACILITY TYPE:	740
ADDRESS:	2430 BANCROFT LANE		TELEPHONE:	(510) 734-3890
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	6	CENSUS: 3	DATE:	07/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Maria Riformo, Administrator		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/08/2021 at 01:10PM, Licensing Program Analysts (LPAs) L. Hall arrived and C. Fowler unannounced to conduct an Infection Control Inspection. LPAs telephoned Administrator for entry. LPAs met with Maria Riformo, Administrator at 1;40pm and explained the purpose of the visit. Upon entry, LPAs was not screened. LPAs did not observe screening station. COVID-19 signs were posted on front door. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, backyard, and kitchen. LPAs observed cough etiquette and physical distancing posted in the common areas. During record review, LPAs observed visitors log for both residents and staff. LPAs observed facility did not have a copy of the Mitigation Plan on file, but Administrator was able to provide email where mitigation plan was submitted. The following deficiencies were observed: -On 7/8/2021 at 1:55PM, LPAs observed bathtub, shower, sinks with soap scum. LPAs observed a dead insect inside of refrigerator freezer, and spilled food and liquid inside refrigerator. Tile flooring throughout facility had debris on sides of refrigerators, stove, sides of cabinets, underneath cabinets, near and baseboards. -On 7/8/2021 at 2:05PM, LPAs observed unlocked shed, wooden boards, garden tools (shovel, a rake, 2 gardening hoes, and paint roller and pan) in backyard. Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

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: DIVINE'S HOME	FACILITY NUMBER: 071441217
	VISIT DATE: 07/08/2021

NARRATIVE

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Continued from LIC809.

Please submit the following documents to CCLD by 7/15/2021.

- Emergency disaster plan (LIC610E).
- Staff roster (LIC500).

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal rights and copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

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: DIVINE'S HOME	FACILITY NUMBER: 071441217
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

87309 Storage Spaces (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in shed in backyard not being locked, garden tools, wooden planks, paint roller and pan inaccesible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/09/2021
	Plan of Correction
1 2 3 4	Administrator agreed to lock shed, make tools inacessible, discard paint roller and pan, and remove wooden planks. Locking of shed, discarding of paint roller and pan, and making tools inacessible were cleared during visit. Administrator agreed to removed wooden planks and submit photo 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC809 (FAS) - (06/04)

Page: 3 of 7

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: DIVINE'S HOME	FACILITY NUMBER: 071441217
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs, the licensee did not comply with the section cited above in bathrooms, refrigerator, and tile floor being unsanitary which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/15/2021
	Plan of Correction
1 2 3 4	Administrator agreed to clean and sanitize bathrooms, refrigerator, and floors. Administrator will submit photos 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC809 (FAS) - (06/04)

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