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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601041
Report Date: 03/07/2025
Date Signed: 03/07/2025 12:38:13 PM

Document Has Been Signed on 03/07/2025 12:38 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GINES RESIDENTIAL CARE HOME IIIFACILITY NUMBER:
075601041
ADMINISTRATOR/
DIRECTOR:		GINES, ERLINDAFACILITY TYPE:
740
ADDRESS:2565 STONE VALLEY ROADTELEPHONE:
(925) 743-1146
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY: 6CENSUS: 6DATE:
03/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Licensee, Erlinda GinesTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 3/07/2025 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee, Erlinda Gines and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory.

LPA toured facility with Licensee including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. Heater is currently out of service since 3/6/2025 and is scheduled for repair 3/7/2025 temperature is maintained at 58 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on 04/13/2024. Emergency Disaster Plan not available. First aid kit was observed to be complete.

At 10am, LPA reviewed 6 residents records. At 10:40 am, LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility.

Report Continues on LIC809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GINES RESIDENTIAL CARE HOME III
FACILITY NUMBER: 075601041
VISIT DATE: 03/07/2025
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • LPA observed kitchen drawer unlocked with butcher Knife and kitchen scissors
  • LPA observed the medication cabinet unlocked and over the counter medication unlocked in kitchen cabinet used by staff.
  • LPA observed staff working at facility that is listed as excluded in Guardian. $500 civil penalty
  • Facility does not have an updated/current emergency disaster plan
  • Facility does not have records of emergency disaster drills


***Civil Penalties in the amount of $500 are being assessed on todays date***

Administrator had to leave the visit early and Licensee approved caregiver to sign report.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/07/2025 12:38 PM - It Cannot Be Edited


Created By: Alona Gomez On 03/07/2025 at 12:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GINES RESIDENTIAL CARE HOME III
FACILITY NUMBER: 075601041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having unlocked sharps which poses an immediate safety risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Facility staff locked away all sharps POC clear.
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above inhaving a staff working at the facility that has been excluded in guardian which poses an immediate safety and personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Staff removed all belongings and left the facility POC clear. LPA also assesed an immediate $500 civil penalty.
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
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/07/2025 12:38 PM - It Cannot Be Edited


Created By: Alona Gomez On 03/07/2025 at 12:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GINES RESIDENTIAL CARE HOME III
FACILITY NUMBER: 075601041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having the medication cabinent unlocked and accesable which poses an immediate safety risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Staff locked and secured the cabinent POC clear.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/07/2025 12:38 PM - It Cannot Be Edited


Created By: Alona Gomez On 03/07/2025 at 12:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GINES RESIDENTIAL CARE HOME III
FACILITY NUMBER: 075601041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above innot having an updated emergency disaster plan which poses a potential safety risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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By POC Licensee agrees to update and review emergency disaster plan and mail a copy to CCLD.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above innot having any record or dates for drills conducted which poses a potential safety risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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By POC Licensee agrees to conduct emergency disaster drills and mail a copy of the logs to CCLD.
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
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
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