075601151-5-17-2022-15-AS-JSAR-CEHVLF-20220517163153

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601151
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:34:42 PM

Document Has Been Signed on 05/17/2022 04:34 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:	AG HEALTH CARE, INC.		FACILITY NUMBER:	075601151
ADMINISTRATOR:	OSHINOWO, ANTHONY		FACILITY TYPE:	740
ADDRESS:	135 LOS CERROS AVENUE		TELEPHONE:	(925) 935-9626
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 5	DATE:	05/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Olubunmi "Anthony" Oshinowo		TIME COMPLETED:	05:00 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 05/17/22 at 12:15PM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with S1 and S2 upon entry who assisted in the tour of the facility inside and outside until Administrator Olubunmi "Anthony" Oshinowo arrived at approximately 1:00PM. Facility has a COVID-19 mitigation plan in place dated 03/03/21 that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. All staff and clients have been fully vaccinated. The LPA and Administrator discussed the infection control plan from the PIN 22-13-ASC that will need to be created for the 06/30/22 due date. However, they were issued a citation for not having the required 30 day supply of PPE. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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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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: 05/17/2022

NARRATIVE

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A written Emergency/Disaster plan completed in 2019 was posted on the bulletin board for staff, clients and visitors to read. Centrally stored medications were in locked cabinets adjacent to the kitchen. The temperature inside of the facility was 81.3 degrees and the hot water was 110 degrees, both within the safe range. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were stored in a locked closets and cabinets.

Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged and the Smoke and Carbon monoxide detectors were operational.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/24/22:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan (update if needed)
· Evidence of Liability Insurance & Surety Bond

Facility cited with 3 Type B deficiencies:

Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/17/2022 04:34 PM - It Cannot Be Edited

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: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Gates into the back yard are falling apart, and in that state of disrepair they are very difficult open and for a resident in an emergency potentially impossible to open which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2022
	Plan of Correction
1 2 3 4	Licensee shall have the gates repaired by the POC due date along with pictures, video, receipts, and/or licensee attestation sent to the LPA to verify that correction.

Type B

Section Cited

CCR

87555(b)(9)

General Food Service Requirements

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above with opened food stored in the refrigerator and freezer without a date on them, as well as kitchen counters and refrigerator/freezer in need of a deep clean to remove caked on dirt and grime. in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2022
	Plan of Correction
1 2 3 4	Licensee shall have all of the opened food dated and the deep clean of the kitchen counters and refrigerator/freezer by the POC due date along with pictures, video, receipts, and/or licensee attestation sent to the LPA to verify that correction.

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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 05/17/2022 04:34 PM - It Cannot Be Edited

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: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

Tit. 22, § 87468.1 - Personal Rights of Residents In all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the facility does not have a 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles) and a list including items on hand or indicating where such items will be acquired (such as CCL Regional Office) and when posing a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2022
	Plan of Correction
1 2 3 4	Licensee shall acquire and store at the facility a 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles). Licensee shall provide proof to the LPA by the POC due 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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