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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601355
Report Date: 09/29/2022
Date Signed: 09/29/2022 09:58:16 AM


Document Has Been Signed on 09/29/2022 09:58 AM - 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: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: 4DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Angelito Marable, Licensee TIME COMPLETED:
10:13 AM
NARRATIVE
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On 09/29/22 at 08:44 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Licensee Angelito Marable and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks.

LPA also advised staff to let administrator know that their annual fee is past due and needs to be paid as soon as possible to avoid additional late fees.

The following deficiency was observed during the visit:
LPA observed that the facility does not have a sufficient 2-day perishable and one week non-perishable food supply for its residents.

The Facility was cited and citations can be found on the LIC 809-D. Exit interview conducted.

Appeal Rights and a copy of this report provided. Exit interview conducted.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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 09/29/2022 09:58 AM - 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: APPLE GARDENS HOME
FACILITY NUMBER: 075601355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 because they do not have a enough food at the facility for a one week of nonperishable and two day perishable supply, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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The facility will purchase additional food and send proof of correction 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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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