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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600294
Report Date: 08/04/2022
Date Signed: 08/04/2022 12:12:51 PM


Document Has Been Signed on 08/04/2022 12:12 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:ABRAHAM REST HOMEFACILITY NUMBER:
075600294
ADMINISTRATOR:SANCHEZ, ALEXFACILITY TYPE:
740
ADDRESS:1095 BANCROFT COURTTELEPHONE:
(925) 945-7398
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alex Sanchez and Sarah AbrahamTIME COMPLETED:
12:30 PM
NARRATIVE
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On 08/4/22 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair and Licensing Program Manager (LPM) H. Humpal conducted an infection control annual inspection. Upon entry into facility, LPA and LPM explained the purpose of the visit to staff members who called Licensees Alex Sanchez and Sarah Abraham. LPA and LPM toured the facility and met with Licensees when they arrived.

Facility has a Covid-19 Mitigation Plan and an Infection Control Plan that they are following with the exception of front door and adequate indoor Covid-19 signage for which they were cited. The designated infection control leader is the Licensee. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log and a no touch thermometer, hand sanitizer, and face masks. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants.

The facility had a working carbon monoxide detector and smoke detector and the fire extinguisher was fully charged and had been serviced within one (1) year. The Emergency/Disaster plan was posted. Centrally stored medications were in locked cabinets, and sharp objects were stored in locked closets and cabinets.

The facility was cited for 1 of the 2 backyard gates being locked. The facility was cited for hot water at 130 degrees, though the temperature inside of the facility was safe at 78 degrees Fahrenheit. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

Continues on LIC 809-C . . .
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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 08/04/2022 12:12 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: ABRAHAM REST HOME
FACILITY NUMBER: 075600294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 because the hot water temperature was 130 degrees , which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee will contact LPA by the POC due date to confirm that the hot water temperature has been reduced to the safe level.
Type A
Section Cited
CCR
87705(l)(2)
87705 CARE OF PERSONS WITH DEMENTIA (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

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 in 1 out of 2 backyard gates which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee cleared deficiency during inspection.

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: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2022 12:12 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: ABRAHAM REST HOME
FACILITY NUMBER: 075600294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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 because they had no Covid-19 signs at the front of the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Licensee shall post Covid-19 signage at the front door and in the personal rooms of the residents and send picture proof to LPA by 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: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: ABRAHAM REST HOME
FACILITY NUMBER: 075600294
VISIT DATE: 08/04/2022
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. . . Continued from LIC 809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 08/11/22:
  • LIC500 - Personnel Report
  • LIC308 - Designation of Facility Responsibility
  • LIC610E - Emergency/Disaster Plan
  • Evidence of Liability Insurance

Facility cited with 2 Type A and 1 Type B deficiencies during this visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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