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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601137
Report Date: 02/21/2023
Date Signed: 02/21/2023 03:17:47 PM

Document Has Been Signed on 02/21/2023 03:17 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:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Anothony Guevarra, CaregiverTIME COMPLETED:
03:40 PM
NARRATIVE
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On 02/21/2023 at 12:00 pm, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct Infection Control Inspection. LPA met with Caregiver Anothony Guevarra, and explained the purpose of the visit. Administrator Agnes Fernandez arrived at 1:20pm.

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. 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.

LPA observed the following deficiencies:

At-12:00pm LPA observed 2 staff working that are not associated to the facility.
At-12:09pm LPA observed half bed rail for resident without Physician orders.
At-12:12pm LPA observed Lysol & Clorox spray located in unlocked kitchen pantry.
At-12:18pm LPA observed 2 ladders, bed frames, mattresses located in unlocked garage.
At-12:25pm LPA observed 3 shovels, screen door, lawn mower, propane tank, book shelf located in the backyard.

CONTINUE ON LIC9099-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PRIORITY CARE HOME I
FACILITY NUMBER: 075601137
VISIT DATE: 02/21/2023
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CONTINUE FROM LIC809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/28/2023:

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 deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Caregiver. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
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Document Has Been Signed on 02/21/2023 03:17 PM - It Cannot Be Edited


Created By: Carol Fowler On 02/21/2023 at 02:28 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: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 observation, interview, the licensee did not comply with the section cited above by having two staff members working that are not associated to the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/22/2023
Plan of Correction
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2 staff members left the facility. Administrator agreed to read and understand the regulation and provide CCLD a self certification no later then the POC date.
Type A
Section Cited
CCR
87309(a)
87309 Storage Spaces

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having Lysol and Clorox spray in an unlocked kitchen pantry which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Administrator agreeded to read and understand the regulation and conduct a training with staff and send a signed certificate with staff signitures to CCLD no later then the POC date.
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: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/21/2023 03:17 PM - It Cannot Be Edited


Created By: Carol Fowler On 02/21/2023 at 02:39 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: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)

87608(a)(3) Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide ... Postural supports may be... (3) A written order from a physician indicating... postural support shall be maintained... require other additional ...This requirement was not met as evidence by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation licensee did not comply with the section cited above by not having a written Physician order for bed rails for R1, which poses a potential health and safety risk to residents in care.
POC Due Date: 03/07/2023
Plan of Correction
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Licensee agreed to submit a written Physician order for bedrails for R1, CCLD no later then the POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023


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