075600924-6-14-2021-15-AS-DPAO-C3YV5P-20210614160818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600924
Report Date: 06/14/2021
Date Signed: 06/14/2021 04:08:36 PM

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:	BRITTANY CARE HOME		FACILITY NUMBER:	075600924
ADMINISTRATOR:	CYNTHIA P. DINGLASAN		FACILITY TYPE:	740
ADDRESS:	871 BRITTANY LANE		TELEPHONE:	(925) 822-3442
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	6	CENSUS: 5	DATE:	06/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Gaudencio Lagua, Lead Staff		TIME COMPLETED:	04:15 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 06/14/21 at 2:10PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with lead caregiver. LPA spoke with administrator on the phone who authorized lead caregiver to sign the reports since administrator was not available at the facility during visit. LPA observed 3 staff wearing face masks during visit. Facility has a completed mitigation plan in place dated 01/19/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with lead caregiver as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. LPA observed staff perform routine symptom screening (+/-) temperature and symptom check) at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. LPA observed paper towels available in residents' bathrooms. LPA observed some trash bins are not foot operated and required staff to open the lid manually. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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: BRITTANY CARE HOME	FACILITY NUMBER: 075600924
	VISIT DATE: 06/14/2021

NARRATIVE

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Sharp objects were locked in the kitchen drawers. Toxic chemicals were locked in the laundry/garage areas. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. A written Emergency/Disaster plan dated 11/11/20 was posted near the main entrance hallway. Centrally stored medications were locked in kitchen cabinets. Sharp objects were locked in the kitchen drawers. Medications were observed locked in the counter cabinets. LPA was also given a completed copy of the mitigation report dated 1/19/2021 by the lead caregiver.

Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 3, 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the kitchen/garage areas. Facility room temperature was maintained at 75 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged and last inspected on 03/29/21. Smoke and Carbon monoxide detectors were operational.

Updated copies of the following documents were given by lead caregiver to LPA during visit:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

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