075601547-12-10-2024-15-AS-DPAO-DBTUB4-20241210142542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601547
Report Date: 12/10/2024
Date Signed: 12/10/2024 02:26:06 PM

Document Has Been Signed on 12/10/2024 02:26 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:	COUNTRY PLACE ASSISTED LIVING		FACILITY NUMBER:	075601547
ADMINISTRATOR/ DIRECTOR:	RICHARDSON, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1715 OLIVE LANE		TELEPHONE:	(925) 778-5000
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY: 49	TOTAL ENROLLED CHILDREN: 0	CENSUS: 40	DATE:	12/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Shani Edwards, Administrator (ADM1) Sherri Richardson, Administrator (ADM)		TIME VISIT/ INSPECTION COMPLETED:	03:00 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	On 12/10/24 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM1) and explained the purpose of the visit. ADM has a current administrator certificate # 6024408740 which expires 01/25/2025. LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand washing signs were observed posted in common areas. Facility has a 30-day supply of PPEs, paper, medications locked in medication room cabinets. Comfortable temperature was observed at 73 deg F per thermostat reading. Hot water temperature was measured at 111 deg F. Fire extinguishers were observed fully charged. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. The following deficiencies were observed during inspection: Absence of a screening station for COVID-19 symptom checks. Four (4) expired fire extinguishers re-inspection tags Emergency/Disaster quarterly fire drills documentation missing Continued on next page, LIC 809-C

Bennett Fong	TELEPHONE: (510) 622-2621
Daisy Panlilio	TELEPHONE: (510) 286-4201
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
	VISIT DATE: 12/10/2024

NARRATIVE

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Updated copies of the following documents were obtained from administrator:
 LIC500- Personnel Report
 LIC9020 - Resident Roster
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/10/2024 02:26 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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

This requirement is not met as evidenced by:(a) A licensee shall ensure that infection control practices are maintained.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to the absence of a COVID-19 screening station which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	By POC due date, ADM agrees to submit proof of correction to CCL to be in compliance with Title 22 regulations Section 87470 Infection Control requirements.

Section Cited

This requirement is not met as evidenced by: 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
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due expired fire extinguisher tags which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	By POC due date, ADM agrees to submit to CCL proof of correction (photos of re-inspected fire extinguishers with current tags) in compliance with Title 2 Section 87203 Fire Safety.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) 622-2621
Daisy Panlilio	TELEPHONE: (510) 286-4201
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/10/2024 02:26 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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

This requirement is not met as evidenced by: The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills.
	Deficient Practice Statement
1 2 3 4	Based on record reviews, the licensee did not comply with the section cited above due to missing emergency/fire drills documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	By POC due date, ADM agrees to submit to CCL proof of correction (completed quarterly emergency & fire drills) to be in compliance with Title 22 Section 87705 (c)(1) regulations.

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.

Bennett Fong	TELEPHONE: (510) 622-2621
Daisy Panlilio	TELEPHONE: (510) 286-4201
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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