079200032-5-18-2023-15-AS-LHAL-CRXQ8R-20230518115710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200032
Report Date: 05/18/2023
Date Signed: 05/18/2023 11:57:32 AM

Document Has Been Signed on 05/18/2023 11:57 AM - 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:	FRANKLIN HOME CARE		FACILITY NUMBER:	079200032
ADMINISTRATOR:	MICHAEL CARIASO		FACILITY TYPE:	735
ADDRESS:	4307 NULL DRIVE		TELEPHONE:	(925) 706-9489
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY: 6		CENSUS: 6	DATE:	05/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Defani Alvarez, Direct Support Professional		TIME COMPLETED:	12:05 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 5/18/2023 at 09:25PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Defani Alvarez, Direct Support Professional, and explained the purpose of the visit. Michael Cariaso, Administrator. The administrator currently holds a certificate (#6060602735) that expires on 09/19/2023. The facility’s fire clearance was approved for six (6) ambulatory clients. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four (4) total bedrooms and two (2 ) bathrooms. One (1) bedroom is occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 107.4 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. Paper goods are sufficient. There is a minimum of 7-day non-perishables and 2-day perishables foods. Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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: FRANKLIN HOME CARE	FACILITY NUMBER: 079200032
	VISIT DATE: 05/18/2023

NARRATIVE

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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 9/15/2022. Emergency Disaster Plan was last posted on 05/12/2022. First aid kit was observed to be complete. Fire drill was last conducted on 12/6/2022.

LPA reviewed all six (6) client records, all were current and complete. All three (3) staff records were current and complete. LPA also reviewed P & I.

The following forms to be updated and submitted to CCLD by 05/25/2023:

Liability insurance.

The following deficiency was observed:

-At 9:45am, LPA observed unlocked cabinet underneath kitchen sink containing toolbox with knives.

Exit interview conducted. A copy of appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/18/2023 11:57 AM - It Cannot Be Edited

Created By: Laura Hall On 05/18/2023 at 11:35 AM

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: FRANKLIN HOME CARE	FACILITY NUMBER: 079200032
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 knives inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	Administrator agreed to obtain a lock and make knives inaccessible from clients and submit photo to CCLD by POC date.

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

LICENSING EVALUATOR NAME:

Laura Hall

LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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