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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600206
Report Date: 10/20/2021
Date Signed: 10/20/2021 04:26:01 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:A & A CARE HOME IFACILITY NUMBER:
075600206
ADMINISTRATOR:BORJA, AMYFACILITY TYPE:
740
ADDRESS:521 FENWAY DRIVETELEPHONE:
(925) 210-0808
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Amy BorjaTIME COMPLETED:
04:44 PM
NARRATIVE
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Licensee Amy Borja. LPA inspected the facility inside and outside. All of the staff and residents were fully vaccinated. Licensee is the designated Infection control leader. The LPA observed that 3 of the 3 staff present wore face masks at all times.

The LPA observed a screening station located near the front entrance with hand sanitizer, a no-touch thermometer, visitor's log, face masks, question concerning and recording of visitor vaccination status for staff, residents, and visitors. LPA observed COVID-19 signs posted in common areas to promote hand washing and physical distancing. Staff documents temperature and health status for staff and residents on a daily basis. The LPA discussed the mitigation plan with the Licensee, as well as their current COVID-19 infection control practices. The Licensee has conducted staff training on infection prevention, symptoms, transmission, as well as the proper donning and doffing of PPE. However, FIT testing has not yet been completed for all of the facility staff members.

There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper and PPE supplies were observed. Facility room temperature was maintained at a comfortable temperature and the hot water was within the safe temperature of 105 to 120 degrees Farenheit. A certified administrator is on site at all times to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged and last inspected in May 2021 and the Smoke and Carbon monoxide detectors were fully operational.

LPA observed one (1) Type B deficiencies, the details of which are in the LIC809-D citations.

Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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: A & A CARE HOME I
FACILITY NUMBER: 075600206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
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: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 with adequate water and food supplies for residents and staff during a disaster or emergency, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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Obtain adequate water and food supplies for residents and staff, during a disaster or emergency. Send proof of the purchase of the water and food to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021
LIC809 (FAS) - (06/04)
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