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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601151
Report Date: 06/26/2021
Date Signed: 06/26/2021 03:42:23 PM

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:AG HEALTH CARE, INC.FACILITY NUMBER:
075601151
ADMINISTRATOR:OSHINOWO, ANTHONYFACILITY TYPE:
740
ADDRESS:135 LOS CERROS AVENUETELEPHONE:
(925) 935-9626
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
06/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ordell Acupan, House ManagerTIME COMPLETED:
03:50 PM
NARRATIVE
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On 06/26/21 at 1PM, Licensing Program Analyst (LPA) conducted an infection control annual inspection and explained the purpose of the visit with S1 and S2. LPA observed Administrator was not available during visit. LPA observed one central entry point designated for universal entry screening at the main entrance. LPA observed visitors' log with a column for temperature logs for residents, staff and visitors. LPA observed thermostat at 83 degrees Fahrenheit. LPA advised staff to adjust the thermostat to 78 degrees Fahrenheit during visit.

LPA observed S1 and S2 were not wearing face masks during visit. LPA advised staff to wear a face mask at all times while working at the facility. Facility has a completed mitigation plan in place dated 03/03/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with staff as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed kitchen fire extinguisher fully charged and last inspected on 01/12/21. LPA observed broken dishwasher in the kitchen and sharps (knife, scissor & pizza cutter) stored in an unlocked kitchen drawer. LPA advised staff to lock the sharps underneath the kitchen sink. Per staff, the designated infection control leader is the administrator.

Continued on next page, LIC 809-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AG HEALTH CARE, INC.
FACILITY NUMBER: 075601151
VISIT DATE: 06/26/2021
NARRATIVE
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All staff and residents have been fully vaccinated since February 2021.There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the kitchen. Smoke and Carbon monoxide detectors were operational. A written Emergency/Disaster plan dated 04/01/19 was displayed in the hallway shelf. Centrally stored medications were locked in kitchen cabinets. Toxic chemicals were locked underneath the kitchen sink.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/07/21:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan (9 pages)
· Evidence of Liability Insurance

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 and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: AG HEALTH CARE, INC.
FACILITY NUMBER: 075601151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)


(f) The following shall be stored inaccessible to residents...
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
Deficient Practice Statement
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This requirement is not met as evidenced by: unlocked knife, scissor and pizza cutter in kitchen drawer which posed an immediate health & safety risk to residents in care.
POC Due Date: 06/26/2021
Plan of Correction
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Deficiency corrected during visit. Staff removed knife, scissor and pizza cutter from unlocked kitchen drawer and locked them underneath the kitchen sink.
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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: AG HEALTH CARE, INC.
FACILITY NUMBER: 075601151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)



This requirement is not met as evidenced by: broken kitchen dishwasher
Deficient Practice Statement
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Based on observation, LPA observed inoperable/broken kitchen dishwasher which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2021
Plan of Correction
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Administrator will submit to CCLD on or before POC due date a copy of purchase receipt for new kitchen dishwasher.
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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6