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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601490
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:02:26 PM


Document Has Been Signed on 05/05/2023 02:02 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:MAUREEN HOUSEFACILITY NUMBER:
075601490
ADMINISTRATOR:JOSE MICHAEL TORIOFACILITY TYPE:
740
ADDRESS:590 MAUREEN LANETELEPHONE:
(925) 818-6536
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 6DATE:
05/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Albert BernardinoTIME COMPLETED:
02:15 PM
NARRATIVE
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On 5/5/23 at 1:00 pm LPA Lori Alexander and LPM Jeremy Fong visited the facility for a separate matter, meeting with S1, S2, S3, and S4, and found that R1 is on oxygen, that the resident is not capable of administering it, and that staff have been assisting R1 with the oxygen. It was also found that the appropriate signage for oxygen usage was not posted.

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

Exit interview conducted and a copy of this report and Appeal Rights were provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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


Document Has Been Signed on 05/05/2023 02:02 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: MAUREEN HOUSE
FACILITY NUMBER: 075601490

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited

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"...the licensee shall be permitted to accept/retain a resident who requires the use of oxygen...under the following circumstances
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Licensee placed a full "No Smoking - Oxygen in Use" sign in the presence of LPA and LPM. Deficiency Cleared.
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..."No Smoking - Oxygen in Use" signes must be posted." This requirement was not met as evidenced by incomplete signage at the front door.
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Type B
05/19/2023
Section Cited

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"...Licensee ...permitted to accept or retain a resident who requires oxygen under the following circumstances...if oxygen
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By POC date, Licensee will submit to CCL a detailed plan as to how R1s oxygen administration will be handled by an appropriately skilled
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administration is performed by an appropriately skilled professional." This requirement was not met as evidenced by staff assisting R1
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professional
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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2