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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200150
Report Date: 03/29/2022
Date Signed: 03/29/2022 11:19:17 AM

Document Has Been Signed on 03/29/2022 11:19 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:APPLETREE ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
079200150
ADMINISTRATOR:NOLITA DAVIDFACILITY TYPE:
735
ADDRESS:2908 SARGENT AVE.TELEPHONE:
(510) 262-0270
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 4CENSUS: 3DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Nolita David, AdministratorTIME COMPLETED:
11:25 AM
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On 03/18/2022 at 9:05 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA rang the doorbell a total of 5 times without the door being answered. LPA saw someone look out of the blinds once on the right side and a second time on the left LPA then rang the doorbell twice after. LPA called the facility and there was no answer, left a voicemail.

A one time civil penalty will be assessed in the amount of $500.

On 3/29/2022 at 8:55AM, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator Nolita David and explained the purpose of the visit.

Upon entry, LPAs observed staff not wearing a mask. LPA also observed there was no screening station, but, there was COVID-19 signage posted . LPAs toured facility including but not limited to common areas, bathrooms, kitchen, garage and outdoor areas. All sinks were equipped with soap and paper towel. Hand washing sign was posted in the bathroom but not the kitchen. Garbage cans needs to be replaced with one that has a lid and step. There was not a sufficient amount of PPE. Facility has a copy of Mitigation Plan on file.

LPA requested the following documents to be updated and submitted to CCLD by 04/05/2022.
  • LIC 610D (Emergency Disaster Plan)
  • Facility roster
  • LIC 500 (Personal report)

Continued on LIC9099C.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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Document Has Been Signed on 03/29/2022 11:19 AM - It Cannot Be Edited


Created By: Carol Fowler On 03/29/2022 at 10:46 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: APPLETREE ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80044(a)
80044 Inspection Authority of the Licensing Agency

(a) The licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1526.5, 1533, 1534, 1538, and 1538.7.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/30/2022
Plan of Correction
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Administrator agreed to submit self-certification letter that the regulation has been read and reviewed to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022


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: APPLETREE ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200150
VISIT DATE: 03/29/2022
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Continued from LIC9099.

No deficiencies were cited during this inspection. Deficiency was cited for attempted visit on 3/18/2022.

The deficiency were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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