075601570-6-29-2021-15-AS-DPAO-C4FRXN-20210629132501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601570
Report Date: 06/29/2021
Date Signed: 06/29/2021 01:25:16 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:	WELCOME HOME SENIOR RESIDENCE(CONCORD)		FACILITY NUMBER:	075601570
ADMINISTRATOR:	CHOU, STEVE		FACILITY TYPE:	740
ADDRESS:	1780 PEACH PLACE		TELEPHONE:	(510) 685-8388
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	6	CENSUS: 4	DATE:	06/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Clara Delgado, Administrator		TIME COMPLETED:	01:40 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 06/29/21 at 12PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 3 staff wearing face masks during visit. LPA observed 2 residents not wearing face masks in the living room watching TV. The other 2 residents were observed resting in their bedrooms. Facility has a mitigation plan in place dated 04/22/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. One central entry point has been designated for universal entry screening with the station located near the front entrance. LPA observed staff check LPA temperature by using the no touch temperature probe and logging the information on the visitor's log. Facility documents daily temperatures and COVID-19 symptom checks for staff, residents and visitors. COVID-19 signs are posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. A written Emergency/Disaster plan dated 04/04/21 was observed posted on the bulletin board near the dining area. Centrally stored medications were locked in the kitchen cabinet island. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were locked in the laundry room. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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: WELCOME HOME SENIOR RESIDENCE(CONCORD)	FACILITY NUMBER: 075601570
	VISIT DATE: 06/29/2021

NARRATIVE

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Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 12, 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the kitchen cabinets and in the garage. Facility room temperature was maintained at 74 degrees Fahrenheit. Resident's bedrooms and bathrooms have COVID-19 signages. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher located in the dining area was observed fully charged and last inspected on 11/19/2020. Smoke and Carbon monoxide detectors were operational.

Adequate supplies of PPE were also observed stored in the laundry room. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants. The facility has auditory signals on each exit door.

Updated copies of the following documents were requested for facility file and to be submitted to CCLD on or before 07/07/21:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC809 (FAS) - (06/04)

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