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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601041
Report Date: 07/26/2022
Date Signed: 07/26/2022 12:32:51 PM

Document Has Been Signed on 07/26/2022 12:32 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:GINES RESIDENTIAL CARE HOME IIIFACILITY NUMBER:
075601041
ADMINISTRATOR:GINES, ERLINDAFACILITY TYPE:
740
ADDRESS:2565 STONE VALLEY ROADTELEPHONE:
(925) 743-1146
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY: 6CENSUS: 5DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Erlinda Gines, AdministratorTIME COMPLETED:
12:50 PM
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On 7/26/2022 starting at 10:40 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPA met with Care Staff, Fely Pisco. Administrator, Erlinda Gines later arrived at 11:24 AM.

LPA toured facility with Care Staff including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins. Facility staff were observed to be wearing proper PPE.

At 11:50 AM, LPA reviewed 3 staff records and 3 of 3 have health screening and TB test on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT:
  • At 11:05 AM, LPA observed a 2x4 block placed against the other side of the side gate which was preventing the gate to open. LPA observed staff remove the block.


REPORT CONTINUES ON 809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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Document Has Been Signed on 07/26/2022 12:32 PM - It Cannot Be Edited


Created By: Lizette Francisco On 07/26/2022 at 12:01 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: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(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
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Based on observation, the licensee did not comply with the section cited above. LPA observed a 2x4 block placed against the side gate thus preventing the gate to open which poses a potential heatth, safetyy or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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LPA observed staff removed block. By POC date, Administrator will review regulation and submit self-certification letter stating Administrator have read and understood regulation.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


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: GINES RESIDENTIAL CARE HOME III
FACILITY NUMBER: 075601041
VISIT DATE: 07/26/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/1/2022.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • Current Administrator’s Certificate


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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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