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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601236
Report Date: 09/02/2022
Date Signed: 09/02/2022 05:15:16 PM


Document Has Been Signed on 09/02/2022 05:15 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:SEIKO'S PLACEFACILITY NUMBER:
075601236
ADMINISTRATOR:LINSZKY, SEIKOFACILITY TYPE:
740
ADDRESS:4967 HAMES DRIVETELEPHONE:
(925) 676-8963
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 5DATE:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Gladys Corpuz, CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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On 9/2/2022 at 12:05PM, Licensing Program Analysts (LPAs) G. Luk and P. Watson arrived unannounced to conduct a Required - 1 Year annual inspection. LPAs met with caregiver, Gladys Corpus. LPAs spoke with Administrator, Crystal Ofahengaue stated that caregiver can sign CCLD reports.

Upon entry, caregiver did not conduct COVID-19 screening for LPAs. LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas.

During record review, LPAs observed a copy of the mitigation plan on file.

At 12:30PM, LPAs observed unlocked medications in room 4 and in the refrigerator.

At 12:40PM, LPAs observed unlocked detergent, sharp tool, and gardening tools. There were keys on knives drawers and cleaning supply cabinet.

At 12:50PM, LPAs were informed that S2 sleeps in room 2 with R1. LPAs observed two beds in room 2 and S2's belongs are stored in the closet taking up half the closet space.

At 1:00PM, LPAs observed S1 is not fingerprint cleared. LPAs observed S1 at the facility.

At 2:00PM, LPAs observed that facility have not submit documents for a change of administrators.

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

LPAs will return at a later time to complete the annual inspection.
Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
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 09/02/2022 05:15 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: SEIKO'S PLACE
FACILITY NUMBER: 075601236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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 unlocked cleaning supplies, detergents, sharp tool, and gardening tools which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/03/2022
Plan of Correction
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Caregiver locked up the drawers/cabinets and pulled out the keys. Detergents were locked up in the garage. Facility has agreed to lock up gardening tools and submit pictures and LIC9098 to CCLD by POC date.
Type A
Section Cited
CCR
87355(e)(1)
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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

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 a staff who is not fingerprint cleared at the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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S1 left the facility during inspection. Facility has agreed to obtain fingerprint clearance for S1 and provide live scan documents to CCLD by POC dates.

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) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 09/02/2022 05:15 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: SEIKO'S PLACE
FACILITY NUMBER: 075601236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 unlocked medications in resident room and refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/03/2022
Plan of Correction
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Caregiver locked up the medications in the resident's room. Facility has agreed to purchase a lock box to lock up the medications in the refrigerator. Facility will send picture proof and LIC9098 to CCLD by 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/02/2022 05:15 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: SEIKO'S PLACE
FACILITY NUMBER: 075601236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(a)
Personal Rights
(a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility.

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 a staff living and having staff belongings in a resident's room which poses a potential personal rights violation to persons in care.
POC Due Date: 09/07/2022
Plan of Correction
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Facility has agreed to move all S2's belongs and second bed out of room 2. Facility will provide picture proof and LIC9098 to CCLD by POC date.
Type B
Section Cited
CCR
87211(g)
Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:

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 by not submitting new administrator documents to CCLD which poses a potential health and safety risk to persons in care.
POC Due Date: 09/07/2022
Plan of Correction
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Facility has agreed to submit documents for administrator change to CCLD by 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5