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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601359
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:25:16 PM


Document Has Been Signed on 10/06/2022 12:25 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:HOME SWEET CARE HOMESFACILITY NUMBER:
075601359
ADMINISTRATOR:SORIANO, CHRISTINE/CORNELLFACILITY TYPE:
740
ADDRESS:1584 DIANDA DRIVETELEPHONE:
(925) 689-2356
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 5DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Christine Soriano, AdministratorTIME COMPLETED:
12:30 PM
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On 10/06/2022 at 9:50 AM, Licensing Program Analyst (LPA) P. Watson and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct an annual Infection Control Inspection. LPA and LPM met with Administrator, Christine Soriano and explained the purpose of the visit. Administrator needed to step up and allowed their caregiver Jet Soriano to sign the forms.

During the Infection Control Inspection, LPA and LPM toured facility with Christine including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, Covid questionnaires, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily.
Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Smoke and carbon monoxide detectors were observed and maintained. Fire extinguisher was observed serviced. LPA and LPM observed facility passages inside and out free of obstruction.

At 10:00 am, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.

Continue on 809 C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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 6


Document Has Been Signed on 10/06/2022 12:25 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: HOME SWEET CARE HOMES
FACILITY NUMBER: 075601359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of person with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


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 by having unlocked gardening tools and a knives which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/07/2022
Plan of Correction
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Administrator agreed to keep items locked away.

Deficiencies cleared during visit. LPA and LPM observed Cargiver putting items away and locking them.
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: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HOME SWEET CARE HOMES
FACILITY NUMBER: 075601359
VISIT DATE: 10/06/2022
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The following deficiency was observed during inspection:

At approximately 10:30 AM LPA and LPM observed an unlocked knife
At approximately 10:30 AM LPA and LPM observed unlocked gardening tools in the backyard

Deficiencies were cleared during the visit. LPA and LPM observed Cargiver putting away and locking items.


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

Exit interview conducted and a copy of this report provided along with Appeal rights.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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