071441217-4-27-2022-15-AS-CFOR-CDVNW4-20220427104854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 071441217
Report Date: 04/27/2022
Date Signed: 04/27/2022 10:49:14 AM

Document Has Been Signed on 04/27/2022 10:49 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:	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: 5	DATE:	04/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Manerissa Taya, Caregiver		TIME COMPLETED:	11:10 AM

NARRATIVE

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On 4/27/2022 at 9:15 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver Manerissa Taya, Caregiver LPA explained the purpose of the visit. Administrator, Matthew Riformmo arrived at 10:05 am.

Upon entry, LPA temperature was checked. LPA observed screening station that contained hand sanitizer, masks and COVID-19 signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPA did not observed visitors log for residents or staff. LPAs observed facility has a copy of Mitigation Plan on file.

The following deficiencies were observed during the visit:

-At 9:33Am, LPA observed unlocked medication.
-At 9:46am, LPA observed a knife located on the kitchen counter top.
-At 9;47am, LPA observed spray Clorox, bleach and other cleaning supplies in a unlocked cabinet located in the hallway.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

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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Document Has Been Signed on 04/27/2022 10:49 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: DIVINE'S HOME	FACILITY NUMBER: 071441217
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)(2)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/28/2022
	Plan of Correction
1 2 3 4	Administrator will provide photo copies of the locked medication cabinet to CCLD no later then the POC date. Knife and cleaning supplies locked during visit, this portion of the deficiency cleared.

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC809 (FAS) - (06/04)

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