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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601497
Report Date:
02/15/2023
Date Signed:
02/15/2023 05:19:12 PM
Document Has Been Signed on
02/15/2023 05:19 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 ELMA
FACILITY TYPE:
740
ADDRESS:
122 LOS ALTOS AVENUE
TELEPHONE:
(925) 954-5329
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94598
CAPACITY:
6
CENSUS:
5
DATE:
02/15/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:45 PM
MET WITH:
Rosa Quiambao
TIME COMPLETED:
05:30 PM
NARRATIVE
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On 02/15/2023 at 2:45 PM, Licensing Program Analyst (LPA) James Sampair began an unannounced annual inspection. LPA explained the purpose of the visit to Licensee Rosa Quiambao. LPA and Licensee inspected the facility inside and outside.
The facility has an infection mitigation plan in place. The Infection Preventionist is the Licensee. Staff were following the latest COVID-19 infection control guidance.
There were at least 7 days of nonperishable and 2 days of perishable foods. Hot water and facility room temperatures maintained at comfortable temperatures. Fire extinguisher was fully charged, but facility cited because it was purchased 02/07/2023, beyond the 1 year that it was required to have been replaced. Carbon monoxide and smoke detectors operational. Administrator is on site a minimum of 20 hours a week to oversee proper business operation.
3 Type-A and 2 Type-B citations issued during inspection.
Administrator to send updated copies of these documents to CCL on or before 02/23/2023:
LIC500 - Personnel Report
LIC308 - Designation of Financial Responsibility
LIC610D - Emergency/Disaster Plan
Evidence of sufficient Liability Insurance
Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
02/15/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/15/2023
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
5
Document Has Been Signed on
02/15/2023 05:19 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
CCLD Regional Office
,
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:
02/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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 in 2 of 2 medicine cabinets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/17/2023
Plan of Correction
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On or before due date, Liceness shall inform LPA that cabinets are locked at all times other than the brief time medications are being prepared for dispensing to residents.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the kitchen where a pair of scissors was stored in an unlocked drawer, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/17/2023
Plan of Correction
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2
3
4
On or before due date, Liceness shall inform LPA that drawers and cabinets storing sharp tools, detergents, and poisons are locked at all times other than the brief time those items are being removed for use.
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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
02/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/15/2023
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
02/15/2023 05:19 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
CCLD Regional Office
,
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:
02/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the kitchen and outside cabinet where detergents and poisons are stored, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/17/2023
Plan of Correction
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2
3
4
On or before due date, Liceness shall inform LPA that drawers and cabinets storing sharp tools, detergents, and poisons are locked at all times other than the brief time those items are being removed for use.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
02/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/15/2023
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
02/15/2023 05:19 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
CCLD Regional Office
,
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:
02/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 not working self-closing gates, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/23/2023
Plan of Correction
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On or before due date, Licensee shall repair or replace the self-closing mechanism to the gates and inform the LPA of their repair.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
02/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/15/2023
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
02/15/2023 05:19 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
CCLD Regional Office
,
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:
02/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire
Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguishers, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/23/2023
Plan of Correction
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2
3
4
On or before due date, Licensee will purchase new fire extinguisher.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
02/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/15/2023
LIC809
(FAS) - (06/04)
Page:
5
of
5