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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601151
Report Date: 05/21/2024
Date Signed: 05/21/2024 12:55:15 PM


Document Has Been Signed on 05/21/2024 12:55 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: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: 4DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver Demarto AcupanTIME COMPLETED:
01:15 PM
NARRATIVE
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On 05/21/2024 at 10:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPA stated the purpose of the visit to Caregiver Demarto Acupan.

The LPA and Mr. Acupan inspected the interior and exterior of the facility, including the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the dining room was measured at 72.1 degrees Fahrenheit at 11:16 AM. Fire extinguisher was fully charged and last serviced on 9/13/2023. The carbon monoxide and smoke detector were fully operational. The LPA observed required postings in the facility. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

The LPA interviewed 1 staff member and 1 resident.

1 B-Type citation issued (refer to LIC809-D for details). 2 Technical Violations issued for violation of regulations that do not pose a risk to the health and safety of persons in care.

The annual inspection is incomplete. The LPA will return unannounced on a future date to complete the inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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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Document Has Been Signed on 05/21/2024 12:55 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: AG HEALTH CARE, INC.
FACILITY NUMBER: 075601151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 1 out of 1 Quarterly Emergency/Disaster Drill records, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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On or before the due date, the Licensee shall ensure that at least 1 emergency / disaster drill has been conducted for every shift. Further, drills shall be scheduled for at least the next 12 months for the facility and the emergency / distaster drill shall be posted.
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: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
LIC809 (FAS) - (06/04)
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