075600757-10-9-2024-15-AS-LHOS-D9W5BK-20241009194849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 10/09/2024
Date Signed: 10/09/2024 07:49:12 PM

Document Has Been Signed on 10/09/2024 07:49 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:	FAMILY COURTYARD		FACILITY NUMBER:	075600757
ADMINISTRATOR:	TEJERO, NORMA		FACILITY TYPE:	740
ADDRESS:	2840 SALESIAN AVENUE		TELEPHONE:	(510) 235-8284
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY:	70	CENSUS: 42	DATE:	10/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Norma Tejero, Administrator		TIME COMPLETED:	08:15 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 10/09/24 at 01:45 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. The Administrator, Norma Tejero (ADM) holds a standard certificate (#6047865740). The facility’s fire clearance was approved for a capacity of seventy (70) all may be non-ambulatory residents. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, masks, COVID-19 signage, and a visitor sign-in log; There is a surplus of face shields, gowns, gloves and other PPE centrally stored inside the facility that is accessible to all care staff. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. LPA toured the facility including but not limited to common areas, bathrooms, kitchen, front and backyard. Medication and sharps were locked, and there was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and garbage cans. Hot water temperature in the shared residents' bathroom was measured at 98 Fahrenheit (F.) and the facility's temperature was 69 degrees F. First aid kit complete. Seven (7) staff and six (6) resident files were reviewed: Resident files need auditing for dates and signatures on Medical Consent forms, the LIC613 and Admission Agreements. The following forms are to be updated and submitted to CCLD: 10/23/24 -LIC500 Personnel Report -LIC308 Designation of Administrative Responsibility (Reviewed) -LIC610 Emergency Disaster Plan (Reviewed) -An updated copy of Administrator Certificate (Reviewed) -Pest Control Report for July - September 2024 Continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FAMILY COURTYARD	FACILITY NUMBER: 075600757
	VISIT DATE: 10/09/2024

NARRATIVE

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...continued from LIC809.

-At around 1:50 PM, LPA observed exit gate and drive thru gate on the right side of building both having pad locks. On the gate of the left side; the pad lock was in place and unlocked at 3:45 PM.
-At around 1:52 PM, LPA observed 2-3 black bed frames, a twin sized mattress, and several various sizes of wooden boards on right side of building.
-At around 1:55 PM, LPA observed two (2) windows without screens and two (2) windows screens that had tears and was in disrepair located on the front side of building. LPA observed One (1) window without a screen and two (2) windows screens that had tears and was in disrepair located on the back side of building at 3:15 PM
-At around 2:43 PM, the water in two separate shared residents' sinks measures at 91 and 98 degrees Farenheit (F.)
-At around 2:50 PM, downstairs bathroom had mildew on the shower curtain, rust stains on the shower floor and around the door perimeter, and three (3)clothes were observed on the floor covering the bottom gaps of the doors. (photos taken)
-At around 3:15 PM, LPA observed 5-6 PVC white tubing, 2-3 wooden pallets on the back side of the facility, 2-3 metal or silver colored strips of material about 10 x 2 feet wide under the gazebo, a tote page with worn looking clothes and plastic garage bags, several wooden boards of various sizes, a gray metal frame similar to the size of a standard coffee table.
-At around 3:50 PM, Two (2) sitting chairs in the hallway were stained with dark colored spots all over the seat. Room #35, dresser has dark smudge prints and floor has small random particles.
-At around 5:04 PM, LPA observed that proof of ADM's 1st aid and CPR was missing from the staff file. (corrected during visit)
-At around 5:07 PM, ADM could not provide proof of liability insurance. (licensee corrected during visit)

Continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FAMILY COURTYARD	FACILITY NUMBER: 075600757
	VISIT DATE: 10/09/2024

NARRATIVE

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...continued from LIC809C.

Deficiencies observed (see LIC809D) and cited from the California Code of Regulations.

Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
-An immediate $500.00 civil penalty will be assessed on today's date for the emergency exit being locked.*

Exit interview conducted, a copy of the LIC421IM, appeal rights and the report provided to Norma Tejedo, ADM.

Physical Plant/Environmental Safety - Row13 - Maintenance and Operation Section 87303(e)(2) - Domain Focused
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/09/2024 07:49 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: FAMILY COURTYARD	FACILITY NUMBER: 075600757
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, and record review the licensee did not comply with the section cited above in 3 out of 3 gates having padlocks attached which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Licensee to review the regulation, provide training to staff and submit proof to CCLD by POC. Locks removed from two gates during the visit to allow emergency exiting on both sides.

Type A

Section Cited

CCR

87307(d)(6)

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. -This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above by having a matress, wooden boards, metal items, and white PVC tubing in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2024
	Plan of Correction
1 2 3 4	Licensee to provide photos to CCLD that the items have been removed by POC date.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/09/2024 07:49 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: FAMILY COURTYARD	FACILITY NUMBER: 075600757
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303

87303 Maintenance and Operation (a) 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, interviews and record review, the licensee did not comply with the section cited above by not providing hot water at a least 105 F., keeping facility free of mildew, and keeping residents' room in sanitary condition which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2024
	Plan of Correction
1 2 3 4	Licensee to inspect facility for repairs, and inspect residents' room for housekeeping needs to include but not limited to cleaning and disinfecting furniture and floor surfaces. Submit photos of room #35, window repairs, and self-certify that other maintenance and operational needs have been met.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

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