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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600354
Report Date: 10/08/2024
Date Signed: 10/08/2024 04:09:10 PM


Document Has Been Signed on 10/08/2024 04:09 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: 5DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Josefina Gardner, Administrator
Roselier Silagan, caregiver		TIME COMPLETED:
04:25 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 10/8/2024 at 11:55AM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with caregiver, Roselier Silagan and explained the purpose of the visit. Administrator, Josefina Gardner, arrived shortly after. The facility’s fire clearance was approved for 6 non-ambulatory residents of which 6 residents may be under hospice care.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 117.6 degrees F in the hallway bathroom. LPAs observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. Last fire drill was conducted on 9/16/2024.

LPAs reviewed 5 residents and 3 staff files starting at 12:20PM. LPAs reviewed a sample of resident's medications during inspection. LPAs interviewed 1 resident and 2 staff starting at 1:45PM.

At 12:48PM, LPAs observed R4 and R5 does not have a current medical assessment on file.

At 1:20PM, LPAs observed unlocked scissors, lighters, and pizza cutter in kitchen drawer. Caregiver locked up the items during inspection.

The deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
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 5


Document Has Been Signed on 10/08/2024 04:09 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: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having unlocked scissors, lighters, pizza cutter in the kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
1
2
3
4
Staff locked the scissors, lighter, and pizza cutter during the visit.

Deficiency cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 10/08/2024 04:09 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: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
(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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having current medical assessment for R4 and R5 which poses a potential health and safety risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
1
2
3
4
The administrator agrees to obtain new medical assessments for R4 and R5 and submit proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5