<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601137
Report Date: 03/18/2022
Date Signed: 03/18/2022 03:35:07 PM

Document Has Been Signed on 03/18/2022 03:35 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:PRIORITY CARE HOME IFACILITY NUMBER:
075601137
ADMINISTRATOR:FERNANDEZ, AGNESFACILITY TYPE:
740
ADDRESS:985 CORAL RIDGE CIRCLETELEPHONE:
(510) 313-0411
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 6CENSUS: 2DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Ana Sto DomingoTIME COMPLETED:
03:45 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 03/18/2022 at 1:40 pm, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct Infection Control Inspection. LPA met with Caregiver Ana Sto Domingo, and explained the purpose of the visit. At 02:20 pm Administrator Agnes Fernandez.

During the Infection Control Inspection, LPA toured facility 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. Visitors policy is posted on the front entrance. 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, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff.


LPAs observed the following deficiencies:

At-2:08pm LPA observed unlocked laundry detergent, lysol, bleach.
At-2:09pm LPA observed tools, hammer, box cutter, screwdriver.

Exit interview conducted a copy of appeal rights and this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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 5
Document Has Been Signed on 03/18/2022 03:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/18/2022 at 03:12 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: PRIORITY CARE HOME I
FACILITY NUMBER: 075601137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)(2)
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).. (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observation licensee did not comply with the section cited above by not maintaining a safe environment with unlocked laundry detergent, bleach, lysol, hammer, box cutter and pliers. which poses an immediate health and safety risk to residents.
POC Due Date: 03/19/2022
Plan of Correction
1
2
3
4
Administrator agreed to turn the garage doorknob around to lock from the outside. Administrator will submit photo copies 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5