075601237-6-16-2021-15-AS-DPAO-C42QTD-20210616122659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601237
Report Date: 06/16/2021
Date Signed: 06/16/2021 12:27:15 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 #2		FACILITY NUMBER:	075601237
ADMINISTRATOR:	LINSZKY, SEIKO		FACILITY TYPE:	740
ADDRESS:	5199 OLIVE DRIVE		TELEPHONE:	(925) 681-3229
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	8	CENSUS: 5	DATE:	06/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Shahid Siddiqui, Administrator		TIME COMPLETED:	12:30 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 06/16/21 at 10:55 AM, Licensing Program Analyst (LPA) conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed S1 wearing face while S2 was not wearing her face mask during visit. LPA requested administrator to remind S2 to wear her face mask daily at all times while working at the facility. LPA observed one central entry point designated for universal entry screening at the main entrance. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Per staff, the designated infection control leader is the administrator. LPA observed COVID-19 signages in common areas. Facility has a completed mitigation plan in place dated 05/26/21 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 locked medication cabinets in the dining area and locked toxic chemical cabinets located inside the laundry area. All staff and residents have been fully vaccinated since February 2021. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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: SEIKO'S PLACE #2	FACILITY NUMBER: 075601237
	VISIT DATE: 06/16/2021

NARRATIVE

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There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 75 degrees Fahrenheit. Fire extinguisher was observed fully charged and last inspected on 09/22/2020. Smoke and Carbon monoxide detectors were operational. A written Emergency/Disaster plan dated 02/05/2021 was observed posted in the dining area. Sharp objects were locked in the kitchen drawer.

Updated copies of the following documents were given by administrator to LPA during visit:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC809 (FAS) - (06/04)

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