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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601497
Report Date: 04/21/2022
Date Signed: 04/25/2022 03:52:04 PM

Document Has Been Signed on 04/25/2022 03:52 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AARON'S ADVANCE CARE HOME INC.FACILITY NUMBER:
075601497
ADMINISTRATOR:QUIAMBAO, ROSA ELMAFACILITY TYPE:
740
ADDRESS:122 LOS ALTOS AVENUETELEPHONE:
(925) 954-5329
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 3DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rosa QuiambaoTIME COMPLETED:
05:00 PM
NARRATIVE
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On 04/21/2022 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced infection control and annual inspection. LPA explained the purpose of the visit and toured the facility with Rosa Quiambao. The LPA observed staff wearing masks as well as a complaint poster, personal rights, Ombudsman and rights to council posters were displayed. LPA observed the 3 residents resting in their bedrooms and watching television during the visit. All staff and all clients are fully vaccinated, including all of the appropriate boosters.

LPA toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. There is sufficient lighting around the facility. Resident's rooms were equipped with the proper furniture and lighting. Resident's rooms had proper bedding and linens. Bathrooms were equipped with grab bars, nonskid mats, and hygiene items. Living room is equipped with the proper furniture for the residents. Hot water temperature was measured at 110 degrees and room temperature at a comfortable 68.7. Sufficient 2 day perishable and 1 week non-perishable food supplies were observed in the refrigerator, freezer, and kitchen cabinets. Passageways and hallways were free of obstruction. Fire extinguisher is fully charged. Smoke and Carbon Monoxide detectors were operational. Medication cabinet was locked and first aid kit was complete.

However, the LPA issued 8 different Type B citations that include: lax Infection Control Practices, Physical Plant and Environmental Safety issues, missing Incidental Medical and Dental documentation, and lacking Disaster Preparedness.

Continued on next page LIC 809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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 6
Document Has Been Signed on 04/25/2022 03:52 PM - It Cannot Be Edited


Created By: James Sampair On 04/21/2022 at 05:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.
FACILITY NUMBER: 075601497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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 because this facility does not have a mitigation plan to mitigate the spread of COVID-19 nor a 30 day supply of PPE. This practice has a health and safety impact that includes, but is not limited to buildings and grounds, personnel requirements, responsibility for providing care and supervision, and personal rights.
POC Due Date: 05/06/2022
Plan of Correction
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Completed COVID-19 mitigation plan and an a 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles). Proof sent to LPA by POC.
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 resident files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Licensee shall create process and records for the residents in care.
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 Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


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Document Has Been Signed on 04/25/2022 03:52 PM - It Cannot Be Edited


Created By: James Sampair On 04/21/2022 at 05:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.
FACILITY NUMBER: 075601497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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The Licensee shall complete a deep clean of the kitchen by the POC due date and send proof to the LPA.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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The Licensee shall clear the junk on the back and side yards and send proof of clearance to LPA by POC due date.
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 Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/25/2022 03:52 PM - It Cannot Be Edited


Created By: James Sampair On 04/21/2022 at 05:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.
FACILITY NUMBER: 075601497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
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Licensee shall lock all of the outside sheds with working locks and provide proof to LPA of the security of those locks by the POC due date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not have proof of CPR training for staff as required which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
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Licensee shall provide proof of training of CPR certification to the LPA by the POC due date.
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 Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/25/2022 03:52 PM - It Cannot Be Edited


Created By: James Sampair On 04/21/2022 at 05:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.
FACILITY NUMBER: 075601497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above because the medication log had not been completed since July of 2021, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Licensee shall update all of the medication logs that were to have been completed and show proof to the LPA before the POC due date.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensee shall purchase and safely store a minimum of 30 gallons of water and an adequate supply of non-perishable food along with a written plan to provide emergency power to be self-reliant for the required period of time. Proof of completion shall be provided to the LPA before the POC due date.
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 Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AARON'S ADVANCE CARE HOME INC.
FACILITY NUMBER: 075601497
VISIT DATE: 04/21/2022
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/05/2022:
• LIC500 - Personnel Report
• LIC308 - Designation of Facility Responsibility
• LIC610D - Emergency/Disaster Plan
• Evidence of Liability Insurance & Surety Bond

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
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