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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600088
Report Date: 08/17/2022
Date Signed: 08/17/2022 02:16:46 PM


Document Has Been Signed on 08/17/2022 02:16 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:CAMINO RAMON HOME FOR SENIORSFACILITY NUMBER:
075600088
ADMINISTRATOR:LINGBANAN, VICTORIAFACILITY TYPE:
740
ADDRESS:931 CAMINO RAMONTELEPHONE:
(925) 838-7786
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 4DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Victoria Lingbanan, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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On 8/17/2022 starting at 11:25 AM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPAs met with Care Staff, Gloria Guzman and LPAs explained the purpose of the visit. Administrator, Victoria Lingbanan later arrived at 12:11 PM.

During the Infection Control Inspection, LPAs toured facility with Care Staff including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a minimum 30-day supply of PPEs maintained at central location and easily accessible for staff.

At 12:25 PM, LPAs reviewed 3 staff records and 3 of 3 have health screening and TB test were maintained on file. Facility has a mitigation plan on file.


REPORT CONTINUES ON 809C

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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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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: CAMINO RAMON HOME FOR SENIORS
FACILITY NUMBER: 075600088
VISIT DATE: 08/17/2022
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED:
  • At 11:55 AM, LPAs observed closet for cleaning supplies and laundry detergents was unlocked. Deficiency cleared during visit.
  • At 11:57 AM, LPAs observed unlocked garden tools along the side of the walk way in the backyard. Deficiency cleared during visit.
  • At 11:58 AM, LPAs observed unlocked gas container and concrete chemicals in the backyard. Deficiency cleared during visit.
  • At 12:00 PM, LPAs observed eggs being stored on a small table. Staff stated it was placed on the table overnight. Deficiency cleared during visit.
  • At 12:30 PM during record review, LPAs observed R1 does not have a current medical assessment.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/26/2022:
  • 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 by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. 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: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 08/17/2022 02:16 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: CAMINO RAMON HOME FOR SENIORS
FACILITY NUMBER: 075600088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

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. LPAs observed store bought eggs were stored on a table overnight which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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DEFICIENCY CLEARED DURING VISIT. LPAs observed staff throw eggs away inside movable bin.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures by 8/26/2022.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(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).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed gardening tools unlocked in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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DEFICIENCY CLEARED DURING VISIT. Administrator removed items and locked it away.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures by 8/26/2022.

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: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 11


Document Has Been Signed on 08/17/2022 02:16 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: CAMINO RAMON HOME FOR SENIORS
FACILITY NUMBER: 075600088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (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
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2
3
4
Based on observation, the licensee did not comply with the section cited above. LPAs observed storage for cleaning and laundry detergents was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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DEFICIENCY CLEARED DURING VISIT. LPAs observed staff locked the padlock for the closet and locked other items away.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures by 8/26/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 11


Document Has Been Signed on 08/17/2022 02:16 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: CAMINO RAMON HOME FOR SENIORS
FACILITY NUMBER: 075600088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPAs observed R1 does not have an updated medical assessment which poses a potential health and safety risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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By POC date, Administrator will obtain an updated Medical Assessment for R1 and submit a copy to CCLD.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 5 of 11