075600757-12-1-2023-15-AS-LHAL-CY53M2-20231201172137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 12/01/2023
Date Signed: 12/01/2023 05:21:49 PM

Document Has Been Signed on 12/01/2023 05:21 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: 41	DATE:	12/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Norma Tejero, Administrator		TIME COMPLETED:	05:30 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 12/1/2023 at 1:05pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Norma Tejero, Administrator, and explained the purpose of the visit. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. LPA did not observe any bodies of water. A comfortable temperature is maintained at 66 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the shared bathroom was measured at 103.9 degree F. One shower room was locked and the other shower room was equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/02/2023. Fire drill was last conducted on 4/5/2023. Six (6) staff records were reviewed and are complete. LPA reviewed eight (8) resident records and all were complete. Continued on LIC809.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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: 12/01/2023

NARRATIVE

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Continued from LIC809.

LPA observed the following deficiencies:

At 2:40pm, LPA observed exit gated and drive thru gate on right side of building both had key padlocks.
At 2:40pm, LPA observed garbage cans, bed frames, window blinds, a table,, and bins located on right side of building
At 2:45pm, LPA observed outside ceiling with cracks and wooden boards put together to hold ceiling up (LPA have pictures).
At 2:55pm, LPA observed facility did not maintain 7-day non-perishables and 2 day perishable food for residents. LPA observed a lot of hot dogs, frozen lasagna, frozen mixed vegetables, frozen pork, milk, eggs, cake mix.
At 3:05pm, LPA observed broken window located on left side of building.
At 3:15PM, LA observed a portable heater in bedroom #40 and was notified the heater for the facility does not work.
At 3:55pm, LPA observed facility did not have a complete first aid kit or any extra first aid supplies.

LPA requested the following documents to be submitted to CCLD by 12/8/2023.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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: 12/01/2023

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Continued from LIC809C.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, 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 emergency exit being locked.*

Exit interview conducted. A copy of the LIC421IM, this report and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/01/2023 05:21 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: 12/01/2023

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, the licensee did not comply with the section cited above in having key padlocks on the exit gate and drive gate on right side of building locked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/02/2023
	Plan of Correction
1 2 3 4	Administrator agreed to remove locks and submit photo 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/01/2023 05:21 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: 12/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 having 7-day perishable and 2-day non perishable foods for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Administrator agreed to purchase food and submit photo and receipts to CCLD by POC date.

Type B

Section Cited

CCR

87465(8)

87465 Incidental Medical and Dental Care (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: 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 having a complete first aid kit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Administrator agreed to purchase a first aid kit and additional first aid supplies and submit photo to CCLD 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 12/01/2023 05:21 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: 12/01/2023

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 observation, the licensee did not comply with the section cited above in have facility's window, ceiling and heater in repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit invoices showing that repairs will be provided or have been completed to CCLD by POC date.

Type B

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, the licensee did not comply with the section cited above in having passageway free of obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have all items removed and submit photo to CCLD 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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