<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600303
Report Date: 05/11/2023
Date Signed: 05/11/2023 01:26:27 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/11/2023 01:26 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:RAMONA CARE HOMEFACILITY NUMBER:
075600303
ADMINISTRATOR:VICTORIA LINGBANANFACILITY TYPE:
740
ADDRESS:2160 RAMONA DRIVETELEPHONE:
(925) 798-4930
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 5DATE:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Josefina Luy and Delma Ong, CaregiversTIME COMPLETED:
01:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/11/2023 11:00 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregivers, Josefina Luy and Delma Ong, and explained the purpose of the visit. The facility’s fire clearance was approved for 6.

LPA toured facility with Josefina including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 1 bedroom is for double occupancy by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 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 103.3.degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide dectector were in operating condition during visit. Fire extinguisher was last serviced on 04/06/21. Emergency Disaster Plan was last posted on 08/30/2017. First aid kit was observed to be complete. No current Emergency Disaster Drill conducted.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: RAMONA CARE HOME
FACILITY NUMBER: 075600303
VISIT DATE: 05/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 11:10 AM, LPA observed RAID Spray, Microban Disinfecting Spray located
unlocked under kitchen sink
At 11:14 AM, LPA observed unlabeled date jars, food containers in the refrigerator
At 11:21 AM, LPA observed Febreeze Fabric Spray, Lysol Spray, disincentive wipes located unlocked in the garage
At 11:36 AM, LPA observed mattresses, wheelchair, toilet commodes, walkers located outside
At 11:38 AM, LPA observed a bathtub and wood planks located outside on the side of the house

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

LPA will return at a later time to complete the inspection.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/11/2023 01:26 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: RAMONA CARE HOME
FACILITY NUMBER: 075600303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2023
Section Cited

1
2
3
4
5
6
7
(f)...shall be stored inaccessible to residents with dementia: (1)...matches, cigarettes ...that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator removed and locked cigarettes and lighters. Deficiency cleared.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by not having cigarettes, lighters, inaccessible to residents which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Type A
05/12/2023
Section Cited

1
2
3
4
5
6
7
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication..cigarettes, and toxic substances such as...cleaning supplies and disinfectants.
1
2
3
4
5
6
7
Administrator removed and locked toxic chemicals. Deficiency cleared.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by not having disinfectant spray, Raid Spray, Lysol Spray inaccessible which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/11/2023 01:26 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: RAMONA CARE HOME
FACILITY NUMBER: 075600303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/18/2023
Section Cited

1
2
3
4
5
6
7
All facilities shall be maintained in...regulations adopted by the State Fire Marshal for the protection ...against fire and panic.
1
2
3
4
5
6
7
Administrator replaced with a new fire extinguisher. Deficiency cleared.
8
9
10
11
12
13
14
Based on observation the licensee did not comply with the section cited above by not obtaining a new fire extinguisher which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
05/25/2023
Section Cited

1
2
3
4
5
6
7
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employess and visitors.
1
2
3
4
5
6
7
Administrator will clean up backyard, side yard and will send photos to CCLD by POC due date
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

mattreesss, wheelchairs, bathtub accessible to clients in care which poses potential health and safety risk to persons in care.
8
9
10
11
12
13
14
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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4