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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600498
Report Date: 05/09/2024
Date Signed: 05/09/2024 07:25:08 PM


Document Has Been Signed on 05/09/2024 07:25 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:ABRAHAM REST HOMEFACILITY NUMBER:
075600498
ADMINISTRATOR:SANCHEZ, JULIO ALEXANDERFACILITY TYPE:
740
ADDRESS:147 CALLE NOGALESTELEPHONE:
(925) 938-9114
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:6CENSUS: 5DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Annette Sanchez, C0-AdministratorTIME COMPLETED:
07:45 PM
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On 05/09/2024 at 3:20 PM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Sara Garcia and explained the purpose of the visit. Sara phoned the Administrators and Victor Rodriguez and Annette Sanchez arrived shortly. The facility’s fire clearance was approved for Six (6) in which all may non-ambulatory of which One (1) may be Bedridden in Bedroom #2. Hospice waiver for Three (3). Administrator Certificate #7002003740 expires 01/28/2026.

LPA toured facility with Annette including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 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 105 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.

LIC809-C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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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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: ABRAHAM REST HOME
FACILITY NUMBER: 075600498
VISIT DATE: 05/09/2024
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LIC809-C Continued...

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/19/2023. Emergency Disaster Plan was last posted on 04/01/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 05/01/2024.

LPA reviewed 5 residents records. LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 05/16/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
Liability Insurance

No deficiencies cited during visit. Exit interview conducted 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: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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