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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601494
Report Date: 12/09/2021
Date Signed: 12/21/2021 02:36:13 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:CARE HOME SWEET HOMEFACILITY NUMBER:
075601494
ADMINISTRATOR:CHONZOM, DICKEYFACILITY TYPE:
740
ADDRESS:316 LILAC CIRCLETELEPHONE:
(510) 799-1287
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 1DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Wenjie Yang, AdministratorTIME COMPLETED:
05:20 PM
NARRATIVE
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On 12/09/2021 at 3:00 pm, Licensing Program Analyst (LPA) C. Fowler conducted a unannounced Infection Control Inspection. LPA met with Administrator, Wenjie Yang and explained the purpose of the visit.

Upon entry, LPA's temperature was not checked. LPA did not observed screening station that contained hand sanitizer, masks or COVID-19 signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA did not observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters. LPA observed facility has a copy of Mitigation Plan on file.

The following deficiencies were observed during the visit:

-At 3:15 pm LPA observed the garage door unlocked with cleaning solutions on an open cabinet.
-At 3:20 pm, LPA observed sharps (knife and scissor) in the kitchen dish drain.


Exit interview conducted with Administrator. A copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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 2
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: CARE HOME SWEET HOME
FACILITY NUMBER: 075601494
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)

(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 observation the licensee did not comply with the section cited above which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 12/09/2021
Plan of Correction
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Administrator corrected deficiency immediately by locking garage door.
Type B
Section Cited
CCR
87705(f)(1)


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 which posed a potential health and safety risk to persons in care.
POC Due Date: 12/09/2021
Plan of Correction
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Administrator corrected deficency immedialy by locking knive and sissors.
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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2