<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601355
Report Date: 10/21/2021
Date Signed: 10/21/2021 05:09:23 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:APPLE GARDENS HOMEFACILITY NUMBER:
075601355
ADMINISTRATOR:MARABLE, ANGELITO I.FACILITY TYPE:
740
ADDRESS:1611 APPLE DRIVETELEPHONE:
(925) 676-9627
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Angelito Marable (Licensee)TIME COMPLETED:
05:20 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 10/21/2021 at 3:15PM, Licensing Program Analysts (LPAs) L. Hall and J. Clancy-Czuleger arrived unannounced to conduct an Infection Control Inspection. LPAs met with Licensee, Angelito Marable and explained the purpose of the visit.

Upon entry, LPAs temperature was checked, and LPAs observed screening station that contained hand sanitizer and log. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, and kitchen. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, garbage with a lid, and hand washing posters were posted.

During record review, LPAs observed visitors log and temperature log for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPE, food, and paper supplies are sufficient.

-On 10/21/2021 at 3:35PM, LPAs observed that staff 2 (S2) was not associated to facility.

The deficiency were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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: APPLE GARDENS HOME
FACILITY NUMBER: 075601355
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(g)(2)
87411 Personal records (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having S2 associated to the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2021
Plan of Correction
1
2
3
4
Administrator agreed to associate S2 and submit a copy of the criminal record clearance to CCLD by POC date. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2