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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200085
Report Date: 10/11/2023
Date Signed: 10/11/2023 03:21:03 PM

Document Has Been Signed on 10/11/2023 03:21 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:MENONA DRIVE CARE HOMEFACILITY NUMBER:
079200085
ADMINISTRATOR:FLORENCIA FLORESFACILITY TYPE:
735
ADDRESS:4586 MENONA DRIVETELEPHONE:
(925) 303-2969
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Florencia Flores, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 10/11/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit.

LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 75 deg F. Hot water temperature was measured at 116 deg F. 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. Fire extinguisher was observed fully charged and last inspected on 06/12/23. LPA reviewed 3 staff and 5 client files. LPA also conducted 3 staff and 2 client interviews during visit.

The following deficiencies were observed during visit:
  • Missing sliding door screen in the kitchen area leading to the back porch
  • Flies in the kitchen dining area

Continued on next page, LIC 9099-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
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: MENONA DRIVE CARE HOME
FACILITY NUMBER: 079200085
VISIT DATE: 10/11/2023
NARRATIVE
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Updated copies of the following documents were collected for facility file:
 LIC500- Personnel Report
 Client Roster
 LIC308- Designation of Facility Responsibility
 LIC610D- Emergency/Disaster Plan including infection control plans
 Evidence of Surety Bond

Exit interview conducted, appeal rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/11/2023 03:21 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 10/11/2023 at 03:03 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: MENONA DRIVE CARE HOME
FACILITY NUMBER: 079200085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors...
This requirement was not met as evidenced by missing sliding door screen in the kitchen area which posed a potential health & safety risk to clients in care.
POC Due Date: 10/31/2023
Plan of Correction
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On or before POC due date, administrator agreed to purchase /install new screen door in the kitchen sliding door and submit to CCL proof of purchase in compliance with Title 22 Section 80087.
Type B
Section Cited
CCR
80087(a)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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The licensee shall take measures to keep the facility free of flies and other insects.
This requirement was not met as evidenced by presence of flies inside the facility which poses a potential health & safety risk to clients in care.
POC Due Date: 10/31/2023
Plan of Correction
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On or before POC due date, administrator agreed to clean, disinfect and eliminate the presence of flies inside the facility in compliance with Title 22 Section 80087 (a)(1).
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:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


LIC809 (FAS) - (06/04)
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