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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601425
Report Date: 12/06/2021
Date Signed: 12/06/2021 01:05:54 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:CRUSE HOUSE ALOHAFACILITY NUMBER:
075601425
ADMINISTRATOR:REYES, VIRGIL T.FACILITY TYPE:
740
ADDRESS:1850 MARINA COURTTELEPHONE:
(925) 338-2056
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 5DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Virgil ReyesTIME COMPLETED:
01:30 PM
NARRATIVE
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On 12/6/2021 Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with S2 . LPA observed 5 residents during the visit. LPA called Administrator Virgil Reyes and explained the purpose of the visit, around 11:45AM Administrator arrived at the facility. Facility was toured with S2. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. A certified Administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.



Continued on next page LIC 809-C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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 4
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: CRUSE HOUSE ALOHA
FACILITY NUMBER: 075601425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on bservation the licensee did not comply with the section cited above on 11:03AM LPA observed disinfectant supplies accessible to residents in care, disinfectant was observed under the unlock kitchen sink cabinet in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2021
Plan of Correction
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Cleared during the visit. S2 locked the kitchen sink cabinet.
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: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: CRUSE HOUSE ALOHA
FACILITY NUMBER: 075601425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(5)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview the licensee did not comply with the section cited above in facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2021
Plan of Correction
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Administrator needs to submit copy of COVID19 training topics with staff signature as proff of training, POC need to be submit on or before the POC date.
Type B
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (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
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Based on interview & record review the licensee did not comply with the section cited above in S2 was not associated at the facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2021
Plan of Correction
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Cleared during the visit. facility Administrator associated S2 using the guardian system.
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: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: CRUSE HOUSE ALOHA
FACILITY NUMBER: 075601425
VISIT DATE: 12/06/2021
NARRATIVE
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LPA observed the following:

· Facility DOES NOT document daily COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility.

· Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use.

· Facility DO NOT have adequate 30-day supply of PPE (e.g., face masks, respirators, gowns, gloves, and eye protection such as face shield or goggles). Per Administrator he will order supplies today and will take a picture of the PPE supplies once receive.

· On 11:03AM LPA observed disinfectant supplies accessible to residents in care, disinfectant was observed under the unlock kitchen sink cabinet. *Cleared during the visit.



· S2 was not associated at the facility. – (cited and corrected during the visit)

· Staff are not FIT tested for N95. LPA provided technical assistance regarding the importance of FIT testing.

· Facility do not have contingency plan for staffing. Technical assistance was provided, LPA requested from the Administrator to submit staffing plan by 12/17/2021.


Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Virgil Reyes.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4