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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601298
Report Date: 04/12/2023
Date Signed: 04/12/2023 01:34:19 PM


Document Has Been Signed on 04/12/2023 01:34 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:PRIORITY CARE HOME IIFACILITY NUMBER:
075601298
ADMINISTRATOR:FERNANDEZ, AGNESFACILITY TYPE:
740
ADDRESS:4387 SANTA RITA ROADTELEPHONE:
(510) 367-2065
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 0DATE:
04/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Agnes Fernandez, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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On 04/12/23 at 12:30 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct Case Management visit as a result of Agnes Fernandez, Administrator/Licensee (ADM) requesting closure of the facility. LPA met with Agnes Fernandez, Administrator (ADM).

Upon arrival, LPA observed that the COVID-19 signage was still present and advised ADM to remove signs from the entrance. LPA was greeted by ADM. LPA and ADM toured the facility's rooms, bathrooms, closets, and outside dwelling. ADM surrendered the facility's license, and will provided copies of the Notices of Eviction to residents, Medication Destruction List for R2 and R3, Personal Property Inventory list for R1, and Death Report(s) for R2 and R3. No residents are on the premises; therefore, it's confirmed the facility is no longer in operation.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct by plan of corrections (POCs) date, and/or repeat violations within 12 months may result in civil penalties.


Exit interview, appeals rights and a copy of this report provided to ADM.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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 04/12/2023 01:34 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: PRIORITY CARE HOME II
FACILITY NUMBER: 075601298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2023
Section Cited

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87224 (c) The licensee shall, in addition to either serving the required thirty (30) days...(60 ) days notice or seeking approval from the Department..., notify or mail a copy of the notice to quit to the resident's responsible person.-This requirement was not met as evidence by:
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Administrator/Licensee shall review Title 22 regulation, 87224, regarding eviction procedures and send self-certification, Death Report, Medication Destruction List for R2 and R3, Personal Property Inventory list for R1 and Eviction Notices by POC date.
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Based on observation and interview, licensee failed to ensure that residents were served with an approved 60 day eviction notice and did not get approval from Community Care Licensing (CCL), which posed a potential risk to residents in care.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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