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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079200037
Report Date:
12/04/2024
Date Signed:
12/04/2024 04:15:58 PM
Document Has Been Signed on
12/04/2024 04:15 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
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER:
079200037
ADMINISTRATOR/
DIRECTOR:
IAN BREMNER
FACILITY TYPE:
775
ADDRESS:
620 LAS JUNTAS
TELEPHONE:
(925) 957-1665
CITY:
MARTINEZ
STATE:
CA
ZIP CODE:
94553
CAPACITY:
20
CENSUS:
17
DATE:
12/04/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:
Michaylie Oslin, Assistant Manager
TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 12/04/2024 at 9:45 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Assistant Manager, Michaylie Oslin and explained the purpose of the visit. Day program operates from 9:00 AM to 4:00 PM. There were six (6) staff observed working with the seventeen (17) clients here today.
LPA toured facility with Michaylie including but not limited to, multiple activity rooms, kitchen, bathrooms and office space. Clients bring their own lunches and snacks. Emergency supplies were observed. The hot water temperature in the clients' bathroom measured 105.1 (downstairs) and 105.3 (upstairs) degrees Fahrenheit. Cleaning supplies are locked and inaccessible to clients. Medications are not handled/dispensed by this program. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition, and additional equipment for the physically handicapped was observed. Incontinent clients are kept clean and dry, and the facility is free of odors. The program has one (1) van used for client outings. Fire extinguishers throughout facility were last inspected 10/23/2024. First aid kit was complete.
LIC809-C Continued
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
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
11
Document Has Been Signed on
12/04/2024 04:15 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
12/04/2024
at
02:33 PM
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:
RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER:
079200037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in by having carbon monoxide detectors which poses a potential health, and safety risk to persons in care.
POC Due Date:
12/27/2024
Plan of Correction
1
2
3
4
Administrator agreed to purchase carbon monoxide detectors, submit a receipt and photo of carbon monoxide detectors installed.
Type B
Section Cited
CCR
82064(d)
Administrator -Qualifications and Duties
(d) The administrator shall receive and document a minimum of 30 clock hours of continuing education every 24 months of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by S2 and S3 having the minimum continuing education (CE) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/27/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit a detail plan to how and when S2 and S3 will receive a miniumum 30hrs of CE and submit copies of certifications to CCLD by POC due date.
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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
12/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
LIC809
(FAS) - (06/04)
Page:
2
of
11
Document Has Been Signed on
12/04/2024 04:15 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
12/04/2024
at
02:33 PM
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:
RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER:
079200037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82064(h)(1)
Administrator -Qualifications and Duties
(h) If an administrator is responsible for two or more adult day programs, there shall be at each site an employee who is responsible for the day-to-day operation of the program and who meets the following qualifications: (1) A baccalaureate degree in psychology, social work or a related human services field; or
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in by having documented degree credentials in S2's and S3's personnel files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/27/2024
Plan of Correction
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2
3
4
Administrator agreed to submit copies of S2's and S3's Bachelor Degrees to CCLD by POC due date. In addition, the copies shall be placed in S2's and S3's personnel files.
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having annual 8hrs training for S2, S3, S4, S6, S7 and S8 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/27/2024
Plan of Correction
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2
3
4
Administrator agreed to submit a detailed plan to how/when the minimum 8hrs DSP training will be completed and send a copy of transcript to CCLD by POC due date.
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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
12/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
12/04/2024 04:15 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
12/04/2024
at
02:33 PM
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:
RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER:
079200037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening, as specified in Section 82065(g).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having a health screening on file for S6 which poses a potential health, and safety risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
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2
3
4
Administrator agreed to submit copy of health screening for S6 to CCLD by POC due date.
Type B
Section Cited
CCR
82066(b)(2)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following information: (2) Tuberculosis test results as specified in Section 82065(g)(1)(B).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having a negative TB result on file for S6 which poses a potential health and safety risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
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2
3
4
Administrator agreed to submit copy of negative TB for S6 to CCLD by POC due date.
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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
12/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
12/04/2024 04:15 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
12/04/2024
at
02:33 PM
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:
RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER:
079200037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having a completed signed admission agreement on file for P5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
1
2
3
4
Administrator agreed to submit a copy of P5's admission agreement to CCLD by POC due date.
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having updated Appraisal Needs and Services (ANS) or RCEB IPP on file for P1-P6 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
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2
3
4
Administrator agreed to self-certify that they read, understand this regulation and submit copies of an updated ANS or IPP for P1-P6 to CCLD by POC due date.
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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
12/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
12/04/2024 04:15 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
12/04/2024
at
02:33 PM
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:
RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER:
079200037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having a negative TB result on file for P5 which poses a potential health, and safety risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
1
2
3
4
Administrator agreed to submit a negative TB result for P5 to CCLD by POC due date.
Type B
Section Cited
CCR
82070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 82069(b).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having a completed medical assessment/Physician's Report (LIC 602) on file for P5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
1
2
3
4
Administrator agreed to submit a completed medical assessment/Physician's Report (LIC 602) for P5 to CCLD by POC due date.
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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
12/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
12/04/2024 04:15 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
12/04/2024
at
02:33 PM
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:
RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER:
079200037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having First Aid and CPR certification on file for S6 which poses a potential health and safety risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
1
2
3
4
Administrator agreed to submit First Aid and CPR certificate for S6 to CCLD by POC due date.
Type B
Section Cited
CCR
82023(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not conducting required disaster drills (e.g. fire drill and earthquake) which poses a potential health and safety risk to persons in care.
POC Due Date:
12/27/2024
Plan of Correction
1
2
3
4
Administrator agreed to self-certify that they read and understand this regulation and will comply with regulation moving forward.
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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
12/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
LIC809
(FAS) - (06/04)
Page:
7
of
11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER:
079200037
VISIT DATE:
12/04/2024
NARRATIVE
1
2
3
4
5
6
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8
9
10
11
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14
15
16
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21
22
23
24
25
26
27
28
29
30
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32
LIC809-C Continued... (Page 2)
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.
The following forms to be updated and submitted to CCL by 12/11/2024:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources - Reviewed
LIC 402 Surety Bond - Reviewed
LIC 500 Personnel Report - Reviewed
LIC 610D Emergency Disaster Plan (Page 9) - Reviewed
Copy Liability Insurance Certificate
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
LIC809
(FAS) - (06/04)
Page:
11
of
11