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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600354
Report Date: 07/29/2024
Date Signed: 07/29/2024 01:02:57 PM


Document Has Been Signed on 07/29/2024 01:02 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:PENNY'S GUEST HOMEFACILITY NUMBER:
075600354
ADMINISTRATOR:EPIFANIA ANGECIAFACILITY TYPE:
740
ADDRESS:1760 AYERS ROADTELEPHONE:
(925) 330-3086
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
07/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Epifania Angcla, AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
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On 7/29/2024 at 12:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Administrator, Epifania Angcla.

While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20240722123621), the following deficiencies were observed.

At 10:30AM, LPA observed unlocked medication in refrigerator. Staff locked up medication during inspection.

At 10:35AM, LPA observed soap and hygiene supplies were stored with non-perishable food items. Staff removed the soap and hygiene supplies during inspection.

At 11:00AM, LPA observed there was a camera in R1's room and the receiver was located in the kitchen counter. Staff removed the camera during inspection.

The 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. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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 07/29/2024 01:02 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: PENNY'S GUEST HOME
FACILITY NUMBER: 075600354

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2024
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible ...This requirement is not met as evidence by:
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Staff locked up the medications during inspection.

Deficiency cleared.
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Based on observation, licensee did not comply with the section cited above by having medications unlocked which poses an immediate health and safety risk to the persons in care.
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Type B
07/30/2024
Section Cited
CCR87555(b)(25)

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General Food Service Requirements. Soaps, detergents...or similar substances shall be stored in areas separate from food supplies.
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Staff removed the soaps and hygiene supplies during inspection.

Deficiency cleared.
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This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by having hygiene supplies stored with food items which poses a potential health and safety risk to the persons in care.
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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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/29/2024 01:02 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: PENNY'S GUEST HOME
FACILITY NUMBER: 075600354

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
CCR
87468.2(a)

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Additional Personal Rights of Residents in Privately Operated Facilities. In addition to...87468.1, Personal Rights...shall have all of the following personal rights: This requirement is not met as evidenced by:
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Staff removed the camera during inspection.

Deficiency cleared
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Based on observation, the licensee did not comply with the section cited above by having a camera in R1's room which poses a potential personal rights risk to persons in care.
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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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3