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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601041
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:33:43 PM

Document Has Been Signed on 11/30/2023 02:33 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:GINES, ERLINDAFACILITY TYPE:
740
ADDRESS:2565 STONE VALLEY ROADTELEPHONE:
(925) 743-1146
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY: 6CENSUS: 5DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Emelia Domingo, CaregiverTIME COMPLETED:
02:50 PM
NARRATIVE
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At 10:35AM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit and met with caregiver, Emelia Domingo. Administrator, Erlinda Gines arrived at approximately 11:00AM. The facility staffs all had criminal record clearances to work at the facility.

LPA toured and inspected the facility inside and outside with administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which five (5) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. The facility has auditory signals on each sliding door in the resident's room. All outdoor and indoor passageways are kept free of obstruction. There were no bodies of water present at this facility. LPA observed medication located in Kitchen and were observed to be locked. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the residents’ shared bathroom was measured at 118.1 degrees F. Resident's bathrooms have grab bars inside the shower. The showers have non-skid mat. Hygiene items, extra linens and toiletry supplies were checked and sufficient. Fire extinguisher in kitchen was last serviced on 4/18/2023, smoke detectors and carbon monoxide were operational. First aid kit was inspected and was complete. Food supplies were sufficient to meet 2-day perishable and 7-day non-perishable requirements.

Resident records were reviewed at approximately 11:15AM. Staff records were reviewed at approximately 12:00 PM.

The following deficiencies were observed;
· At approximately 12:10pm during staff file review LPA observed S1, S2, S3, S4 did not have current First Aid certification.
· At approximately 12:20pm during staff file review LPA observed S5 is not associated to facility.
·At approximately 12:30pm during staff file review LPA observed Administrator file incomplete missing Physicians report, TB screen, and Criminal record statement.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GINES RESIDENTIAL CARE HOME III
FACILITY NUMBER: 075601041
VISIT DATE: 11/30/2023
NARRATIVE
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Continued from LIC809

The following forms are to be updated and submitted to CCLD by 12/11/2023.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (9 pages)
Liability Insurance
Updated Facility floor plan/ Sketch

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, a copy of this report provided and appeal rights provided
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/30/2023 02:33 PM - It Cannot Be Edited


Created By: Alona Gomez On 11/30/2023 at 02:06 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
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:

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 in not having a complete file for administrator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2023
Plan of Correction
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By POC date administrator agrees to submit a checklist for the required documents in admistrator file to CCLD
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements – General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of five staff, the licensee did not comply with the section cited above in not having the required staff first aid certified which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2023
Plan of Correction
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By POC date Administrator agrees to have all required staff first aid trained and certified and submit certificates 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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 02:33 PM - It Cannot Be Edited


Created By: Alona Gomez On 11/30/2023 at 02:18 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in having
S5 not associated to facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2023
Plan of Correction
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By POC date administrator agrees to submit the nessesarry documents to associate S5 and self certify submission to CCLD
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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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