075601490-8-22-2023-15-AS-LAWN-CUXS49-20230822133223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601490
Report Date: 08/22/2023
Date Signed: 08/22/2023 01:32:31 PM

Document Has Been Signed on 08/22/2023 01:32 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 HOUSE		FACILITY NUMBER:	075601490
ADMINISTRATOR:	JOSE MICHAEL TORIO		FACILITY TYPE:	740
ADDRESS:	590 MAUREEN LANE		TELEPHONE:	(925) 818-6536
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 6	DATE:	08/22/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Lea Robes, Caregiver		TIME COMPLETED:	02:00 PM

NARRATIVE

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On 08/22/2023 at 11:15 AM Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla arrived unannounced to conduct a Case Management visit. LPAs met with Caregiver, Lea Robes. The Licensee/Administrator, Albert Bernardino, arrived approximately 1 hour later.

While LPA L. Alexander was conducting file review related to complaint # 15-AS-20230801143742, LPA observed Resident 2 (R2) hospital discharge dated 5/26/2023 indicates R2 Pressure injury of right heel stage 3 ...

During the visit, LPAs obtained the following records:

Admission Agreement
Resident Appraisal
Appraisal/Needs and Services Plan
Functional Capability Assessment
Identification and Emergency Information
Emergency Sheet Maureen House
Durable Power of Attorney for Financial
Release of Client/Resident Medical Information

Continued LIC809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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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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
	VISIT DATE: 08/22/2023

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Continued from LIC809

Attested Discharge Summary (05/26/23)
Hospital Discharge Summary - Contra Costa Health Services (05/26/23)
After Visit Summary - Pittsburg Podiatry (06/08/23)
After Visit Summary - Pittsburg Podiatry (07/20/23)
Admission Notes (12/16/22)
Financial Counseling Addendum (07/13/22)
History & Physical (07/11/22) Faxed 19 pages
Physician's Report for RCFE signed 12/01/22
Covid-19 Test Result (05/26/23)
Power PICC SOLO Catheter Info. (05/18/23)
Blood Pressure Chart, Progress Report notes
Contra Costa Regional Medical Labs (05/17/23 thru 05/25/23)
Client Weight Record
Immunization Summary

LPAs will review documents and issue citations at a later time, if needed.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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