075600618-5-3-2022-15-AS-JSAR-CE3VJE-20220503162837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600618
Report Date: 05/03/2022
Date Signed: 05/03/2022 04:32:54 PM

Document Has Been Signed on 05/03/2022 04:32 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 HOME		FACILITY NUMBER:	075600618
ADMINISTRATOR:	ANNETTE SANCHEZ		FACILITY TYPE:	740
ADDRESS:	2832 FILBERT AVENUE		TELEPHONE:	(925) 287-8382
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 6	DATE:	05/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Annette Sanchez		TIME COMPLETED:	05:00 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 05/03/2022 at 11:30AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with S1 upon entry, who then called the administrator who arrived at 12:15PM. Facility has a mitigation plan (LIC 808) in place dated 02/22/2021 to mitigate the spread of COVID-19. LPA discussed the importance of having an updated infection control plan in accordance with PIN 22-13-ASC. LPA inspected the facility inside and outside. LPA observed the 2 staff assisting 6 of the 6 clients with activities of daily living. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read. There were at least 7 days of nonperishable and 2 days of perishable foods. Centrally stored medications were locked in the cabinets. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were stored in a locked closet inside the laundry room. Infection control designated leader is the administrator. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

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 05/03/2022 04:32 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: 075600618
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(g)

80019 CRIMINAL RECORD CLEARANCE (g) Violation of Section 80019(e) will result in an immediate assessment of a civil penalties of one hundred dollars ($100) per violation per day for a maximum of 5 days by the Department. 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 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2022
	Plan of Correction
1 2 3 4	Associate S2 with facility.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 2 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: 075600618
	VISIT DATE: 05/03/2022

NARRATIVE

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Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged. All staff and 6 clients have been fully vaccinated.

Smoke and Carbon monoxide detectors were operational. Adequate supplies of PPE were also observed stored on the premises. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/10/2022:

· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

Facility cited with 1 Type A and 1 Type B deficiencies.

Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/03/2022 04:32 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: 075600618
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 in the exterior of the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/04/2022
	Plan of Correction
1 2 3 4	Licensee shall repair fence segments, side gate, and wooden deck, and remove pipes, commodes, bags of recycled plastic bottles, and other junk in the backyard. providing proof to the LPA by the POC due 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

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