075601514-1-10-2024-15-AS-AGOZ-CZCV3P-20240110150504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601514
Report Date: 01/10/2024
Date Signed: 01/10/2024 03:05:21 PM

Document Has Been Signed on 01/10/2024 03:05 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	PENNY'S GUEST HOME		FACILITY NUMBER:	075601514
ADMINISTRATOR:	GARDNER, JOSEFINA		FACILITY TYPE:	740
ADDRESS:	78 RYEGATE PLACE		TELEPHONE:	(925) 361-8781
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 4	DATE:	01/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator, Josefina Gardner		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) A Gomez conducted an unannounced 1-Year Annual Required visit on this date starting at 1:20pm. Upon arrival, LPA met Administrator, Josefina Gardner. The facility's fire clearance was approved for six non-ambulatory. Administrator holds a current certificate (#6015433740) that expires 04/09/2024. During the visit, LPA toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, backyard and common areas. A comfortable room temperature is maintained at 73 degrees F. Hot water temperature measured at 114.7 degrees F. There is a minimum of 2-day perishable and one week perishable foods. Indoor and outdoor passageways were kept free of obstruction. There are no bodies of water observed. LPA observed resident's shared bathrooms were equipped with grab bars and non-skid mat. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last bought on 1/10/2024. Emergency Disaster Plan was last posted on 10/20/2023. Fire drill was last conducted on 4/27/2023. First Aid kit was observed complete. LPA reviewed 3 staff records and 3 of 3 staff are associated to the facility and have current first aid training. LPA reviewed 4 residents records and a sample of residents medications. Report continues on 809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PENNY'S GUEST HOME	FACILITY NUMBER: 075601514
	VISIT DATE: 01/10/2024

NARRATIVE

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The Following Deficiencies were Observed:

During Tour LPA observed unlocked cleaning supplies (comet, windex, Clorox cleaner, ect) under kitchen sink and under bathroom sink. Administrator removed and locked away all chemicals clearing the deficiency.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 1/19/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/10/2024 03:05 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PENNY'S GUEST HOME	FACILITY NUMBER: 075601514
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

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. 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 having unocked cleaner which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2024
	Plan of Correction
1 2 3 4	Administrator locked away all chemicals during visit.

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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

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