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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601425
Report Date: 08/29/2023
Date Signed: 08/29/2023 04:04:09 PM


Document Has Been Signed on 08/29/2023 04:04 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
OAKLAND ASC, 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: 6DATE:
08/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michael Bryan Manarang, CaregiverTIME COMPLETED:
04:15 PM
NARRATIVE
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On 8/29/23 at 3:00 PM, AGPA L. Francisco and LPA A. Gomez conducted a case management while at the facility as a result of complaint (CN# 15-AS-20220114083251). AGPA and LPA met with Caregiver, Michael Bryan Manarang and explained the purpose of the visit.

During an interview with 1 of 2 staff, AGPA and LPA discovered that staff are performing R2's glucose level. S1 stated that R2 is not able to perform glucose level independently. AGPA and LPA did not observe an exception on file for R2.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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 08/29/2023 04:04 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: CRUSE HOUSE ALOHA
FACILITY NUMBER: 075601425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
CCR
87628(a)

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87628(a) DIABETES
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication.....
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By POC date, Administrator will review regulation and submit a plan to address R2's diabetic care needs and submit a copy to CCLD.
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This requirement is not met as evidenced by: Based on record review, Licensee did not comply with regulations cited above by not obtaining an exception request for R2. Staff are performing R2's glucose testing which poses an immediate health and safety 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
LIC809 (FAS) - (06/04)
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