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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 09/13/2022
Date Signed: 09/13/2022 07:56:18 PM


Document Has Been Signed on 09/13/2022 07:56 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 COURTYARDFACILITY NUMBER:
075600757
ADMINISTRATOR:TEJERO, NORMAFACILITY TYPE:
740
ADDRESS:2840 SALESIAN AVENUETELEPHONE:
(510) 235-8284
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:70CENSUS: 43DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Medication/Floor Staff, Jiena GuienTIME COMPLETED:
08:15 PM
NARRATIVE
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On 09/13/2022 at 02:20 PM Licensing Program Analysts (LPAs) L. Holmes and M. Malik conducted an unannounced annual infection control inspection. LPAs met with Medication/Floor Staff, Jiena Guien and informed the purpose of visit. LPA L. Holmes spoke to Administrator Norma Tejero and Licensee Juliana Taburaz; both could not be present.Per LIC308, Jiena Guien can sign the report.

Facility has a completed COVID-19 mitigation plan and submitted to Community Care Licensing (CCL).

LPAs inspected the facility inside and out with staff. LPAs observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, masks, and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and visitors. Residents are screened for COVID-19 symptoms and temperature checked daily. LPAs observed COVID-19 signages posted all throughout the facility. Medications are centrally stored in the a locked room. Centrally stored PPEs were unable to be inspected. There were at least 7 days of nonperishable and 2 days of perishable food supplies that were questionable in amount. The Cook stated that groceries are purchased twice a week and a new deliver is for 09/14/2022.

Fire extinguisher was observed fully charged and tag showed serviced November 12, 2021. Smoke and carbon monoxide detectors were operational. First aid kit inspected and observed complete with manual. Hot water temperature in the common bathroom tested and measured at 93.4 degree Fahrenheit (F).



.......continued on 809C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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 9


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: 09/13/2022
NARRATIVE
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...continued from LIC809

The following forms are to be updated and submitted to CCLD: 09/27/2022
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)



LPAs observed the following during course of inspection:
· Approximately at 3:05 PM, LPAs observed sink areas without paper towels in the staff room, staff meeting room #2.
· Approximately At 3:10PM, LPAs observed Care Staff did not have access to all stored PPE. PPE was locked in Room #6.
· Approximately at 3:11 PM, LPAs observed cobwebs, a hanging orange towel, uncovered garbage can in shared sink and toilet area of rooms #14 and #!5. #17 did not have paper towels.
· Approximately at 3:16 PM, LPAs observed 5-6 PPE gowns in room #19.
· Approximately at 3:21 PM, LPAs observed shower room #1, broken uncovered garbage can, sink faucet did not have hot and cold water fixtures, a black hose about 3 feet long in place of a shower hose and head fixture. One shower stall has an out-of-order sign.
· Approximately at 3:22 PM, LPAs observed room #23 with brown faux wood floors buckling in 4-5 places. Brown, left cabinet door to the sink vanity is off the hinges and missing. White vertical window blinds missing vertical pieces and in disrepair.
· Approximately at 3:27 PM, LPAs observed uncovered garbage cans in hallway of room #26 and #29.

continued on LIC809C...
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9
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: 09/13/2022
NARRATIVE
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...continued from LIC809C


· Approximately at 3:37 PM, LPAs observed silver metal grab bar in the bathroom of room #32, unscrewed and separating from the wall, out of order sign was taped to the bathroom door, and white vertical window blinds missing vertical pieces and in disrepair, and one door of the two closet doors was off the hinges and propped against the wall near the bedroom entrance door.
· Approximately at 3:33 PM, LPAs observed dining area; hand washing signs, paper towels and covered garbage cans are needed.
· Approximately at 3:47 PM, LPAs observed shower room #2, what appeared to be mold/mildew on the floor and wall tile fixtures throughout the shower area.
· Approximately at 5:10 PM, LPAs tested water temperature at shower room #2 at 68.6 degrees (F)
· Approximately at 5:12 PM, LPAs tested water temperature at the shared sink near room #26 at 93.4 degree (F)
· Approximately at 6:10 PM, LPAs observed staff toilet in the staff meeting room #2 does not flush.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Copy of report and appeal rights provided to Jiena Guiem.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 09/13/2022 07:56 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: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above. LPA's observed mold/mildew in shower room #1 and #2, and the shared sink area at rooms #14, #15, and room #17 had cobwebs around the sink which poses potential risks to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Administrator will review regulations, conduct in-service training with staff and submit a copy of training agenda with staff signatures and photos of bathrooms and sink areas.
Type B
Section Cited
CCR
87303(e)(4)

87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above. LPAs observed a broken grab bar in the bath room of room #32 which poses a potential health and safety risk to persons in care.
POC Due Date: 09/27/2022
Plan of Correction
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Administrator will review regulations, conduct in-service training with staff and submit a copy of training agenda with staff signatures and photos of grab bar in room #32.

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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 09/13/2022 07:56 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: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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 observations and interviews, the licensee did not comply with the section cited above. LPA's observed closet door and blinds of bedroom #32 and vanity cabinet door and blinds of bedroom #23 in disrepair which poses a potential health and safety risks to persons in care.
POC Due Date: 09/27/2022
Plan of Correction
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Administrator will review regulations, conduct in-service training with staff and submit a copy of training agenda with staff signatures and photos of closet, cabinet and blinds.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9


Document Has Been Signed on 09/13/2022 07:56 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: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows:

(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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above. LPA's observed hot water tempertaure in shower room #2 at 68.6 degree F and 93.4 degree F in the shared common bathroom.
POC Due Date: 09/16/2022
Plan of Correction
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Administrator will review regulations, conduct in-service training with staff and submit a copy of training agenda with staff signatures. Administartor will submit proof of the correction by a certified plumber.
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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 9 of 9