079200110-9-14-2023-15-AS-PWAN-CVNRVH-20230914132135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200110
Report Date: 09/14/2023
Date Signed: 09/14/2023 01:21:45 PM

Document Has Been Signed on 09/14/2023 01:21 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	AVANCARE ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	079200110
ADMINISTRATOR:	CESAR REDOLOSO III		FACILITY TYPE:	735
ADDRESS:	2100 CRISTINA WAY		TELEPHONE:	(925) 308-7586
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY: 6		CENSUS: 6	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Cesar Redoloso III, Administrator		TIME COMPLETED:	01:30 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 09/14/2023 at 9:10 AM, Licensing Program Analysts (LPAs) P. Watson and A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Cesar Redoloso III and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Ambulatory. LPA toured the facility with Cesar including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degree Fahrenheit. LPAs 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 134.2 degree Fahrenheit, hot water was checked again and measured at 127.0 degree Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. The supply of extra hygiene’s were available for clients. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/25/2022. First aid kit was observed to be complete. Fire drill was last conducted on 09/02/2023. Report continues 809 C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AVANCARE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 079200110
	VISIT DATE: 09/14/2023

NARRATIVE

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At 9:30 AM, LPA reviewed 6 of 6 residents records. At 10:00 AM, LPA reviewed 5 of 10 staff records and 5 of 5 have current first aid training and associated to the facility. At 11:30 AM, LPA reviewed a sample of 6 of 6 resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/05/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 D Emergency Disaster Plan

The following deficiency was observed during inspection:
-At approximately 12:35 PM hot in residents shared bathroom was measured at 134.2 degrees Fahrenheit. At approximately 1:03 PM hot water was checked again and measured at 127.0 degrees Fahrenheit.

The following deficiencies were observed (see LIC 809 D) 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.

Exit interview conducted and a copy of this report provided along with Appeal rights

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/14/2023 01:21 PM - It Cannot Be Edited

Created By: Paris Watson On 09/14/2023 at 01:06 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: AVANCARE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 079200110
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

80088(e)(1) Furniture, Fixtures, Equipment, and Supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, hot water in the residents shared bathroom was measured at 127.0 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Administrator will adjust water heater, re-test hot water and provide photographic proof that hot water is within range (105 degrees F - 120 degrees F) to CCL 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:

Yvonne Flores-Larios

LICENSING EVALUATOR NAME:

Paris Watson

LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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