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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601237
Report Date: 03/01/2021
Date Signed: 03/01/2021 03:59:32 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:SEIKO'S PLACE #2FACILITY NUMBER:
075601237
ADMINISTRATOR:LINSZKY, SEIKOFACILITY TYPE:
740
ADDRESS:5199 OLIVE DRIVETELEPHONE:
(925) 681-3229
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:8CENSUS: 5DATE:
03/01/2021
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shahid SiddiquiTIME COMPLETED:
04:00 PM
NARRATIVE
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On 03/01/2021, Licensing Program Analysts (LPAs) Allison O'Hollaren and Lizette Francisco conducted a case management tele-visit via Microsoft Teams due to Shelter in Place order directed by the Governor. LPAs spoke with Administrator Shahid Siddiqui.

While conducting a tele-visit for another matter, LPAs observed laundry detergent in resident bathroom underneath sink. LPAs also observed laundry room unlocked with laundry detergent accessible to residents. In addition, LPAs observed TV, TV stand and dresser blocking emergency exit door in resident's bedroom and unsecured cord in front of the door. When LPAs asked to open emergency exit door, door would not open from inside and then staff opened door from outside. Door was then able to lock and unlock inside resident's bedroom.

The following deficiencies were cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.



Exit interview conducted. Appeal Rights and a copy of this report emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
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 2
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 #2
FACILITY NUMBER: 075601237
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2021
Section Cited

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87307 (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement was not met as
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evidenced by: LPAs observed Tv, TV stand and dresser blocking emergency exit door in resident's bedroom, unsecured cord in front of the door, and door would not open from inside room.
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Type B
03/08/2021
Section Cited

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87309 (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. (1) Storage areas for poisons...and
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other dangerous weapons shall be locked. This requirement was not met as evidenced by: LPAs observed laundry detergent underneath resident bathroom sink and laundry detergent in unlocked laundry room.
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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: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2021
LIC809 (FAS) - (06/04)
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