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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
071441217
Report Date:
03/25/2024
Date Signed:
03/25/2024 04:42:59 PM
Document Has Been Signed on
03/25/2024 04:42 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
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:
1
DATE:
03/25/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:17 PM
MET WITH:
MARIA RIFORMO, ADMINISTRATOR
TIME COMPLETED:
05:10 PM
NARRATIVE
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On 3/25/2024 at 1:17pm Licensing Program Analysts (LPA) Carol Fowler arrived to conduct an unannounced Annual Required visit. There was no one at the facility Administrator arrived with husband and resident at 1:37pm. LPA met with Administrator, Maria Riformo. The Administrator currently holds a certificate (#6006016740) that expires on 04/06/2025. The facility’s fire clearance was approved for 6 residents, which 5 may be non-ambulatory and one (1) ambulatory.
LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which one (1) bedrooms 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 70 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 131.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.
Smoke detectors is in operating condition during visit, the carbon monoxide detector is not
in operating condition
Fire extinguisher was last serviced on 5/23/2023. There is no record of the Emergency Disaster Drills being conducted. First aid kit was observed to be complete. No record of last Fire drill.
LPA reviewed 2 staff records which were incomplete and 1 of 1 residents record which was complete.
Report Continues on 809C
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
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
8
Document Has Been Signed on
03/25/2024 04:42 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
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:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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.
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 by having chemicals such as Ajax, Windex and cleaning vinegar unlocked which poses an immediate health and safety rights risk to persons in care.
POC Due Date:
03/26/2024
Plan of Correction
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Administrator agreed to keep all chemicals locked at all times. DEFICIENCY CLEARED DURING VISIT.
Type A
Section Cited
CCR
87465(h)(2)
(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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having unlocked medication in the laundry and unlocked staff room which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/26/2024
Plan of Correction
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2
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Administrator agreed to read the regulation and self certify about the importance of having medication unlocked and accessible to residents in care by the POC date.
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:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
03/25/2024 04:42 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
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:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
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 not having a carbon monoxide detector in operating condition which poses a potential health and safety risk to persons in care.
POC Due Date:
04/01/2024
Plan of Correction
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2
3
4
Administrator will purchase new carbon monoxide detectors and provide CCL a copy of the receipt via email by the POC date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above by not having a current CPR certificate which poses potential health and safety risk to persons in care.
POC Due Date:
04/08/2024
Plan of Correction
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2
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4
Administrator will renew her CPR/First - Aid training and email a copy to CCLD by the POC date.
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:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
03/25/2024 04:42 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
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:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by having incomplete staff records which poses a potential health and safety risk to persons in care.
POC Due Date:
04/08/2024
Plan of Correction
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2
3
4
Administrator agreed to read the regulation and provide CCLD with a check list of documents needed in the staff files along with a sample copy of the updated files by the POC date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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 having expired can goods and molded foods in the refrigerator which poses a potential health and safety risk to persons in care.
POC Due Date:
04/08/2024
Plan of Correction
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Administrator agreed to take inventory on can goods and purchase new can goods and fresh vegetables and provide CCLD a copy of the can goods and fresh vegetables along with a copy of the receipt via email by the POC date.
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:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
03/25/2024 04:42 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
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:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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 not having the resident medication at the facility which poses a potential health and safety risk to persons in care.
POC Due Date:
03/01/2024
Plan of Correction
1
2
3
4
Administrator will provide a picture of residents medication being centrally stored at the facility along with a current MAR to CCLD by POC date.
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 interview and record review, the licensee did not comply with the section cited above by not having an emergency and disaster plan at the facility which poses a potential health and safety or personal rights risk to persons in care.
POC Due Date:
04/01/2024
Plan of Correction
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2
3
4
Administrator agreed to read the regulation and complete the emergency and disaster plan and email a copy to CCLD by the POC date.
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:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
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:
03/25/2024
NARRATIVE
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Continued from LIC809
LPA observed the following deficiencies:
- at 1:56pm. LPA observed expired can goods and molded vegetables located in kitchen cabinet and refrigerator.
- at 1:59pm. LPA observed Ajax, Windex, senna, sleep aid, melatonin in an unlocked cabinet in the laundry room.
- at 2:00pm, LPA observed a hoe, shovel, commode and 4 chairs, trash, wood planks located in the backyard.
- at 2:06pm. LPA observed an unlocked storage unit witch contained a ladder paint and other boxed and bagged items.
- at 2:09pm. LPA observed unlocked staff room with medication.
- at 2:11pm, LPA observed scissors in an unlocked file cabinet in the dining area.
- at 2:11pm, LPA observed resident medication not at the facility and the MAR not updated.
- at 2:15pm, LPA observed incomplete staff files, During interview with staff ADM CPR expired.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/04/2024:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
03/25/2024 04:42 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
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:
03/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(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.
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 by having items such as wood planks, chairs, trash, hoe, shovel, commode, an unlocked storage with ladder, paint and other boxed and bagged and lock the scissors in the caregivers room items which poses an immediate health and safety risk to persons in care.
POC Due Date:
04/08/2024
Plan of Correction
1
2
3
4
Administrator agreed to remove items from the backyard and keep the storage unit locked at all times by the 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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8