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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200169
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:08:56 PM

Document Has Been Signed on 10/22/2021 03:08 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:PROFESSIONAL ASSISTED LIVINGFACILITY NUMBER:
079200169
ADMINISTRATOR:RAY LANGIT,DARLENE ATIZADOFACILITY TYPE:
735
ADDRESS:852 CORAL DRIVETELEPHONE:
(510) 245-7234
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 6CENSUS: 6DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lorna Nidea, caregiverTIME COMPLETED:
03:20 PM
NARRATIVE
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On 10/22/2021 at 12:50PM, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct an Infection Control Inspection. LPAs met with Lorna Nidea, Caregiver and explained the purpose of the visit. Administrator Darlene Atizado arrived at approximately 2:18pm.

Upon entry, LPA observed hand sanitizer and COVID-19 signs were posted. LPAs toured facility including but not limited to common areas, hand washing stations, bedrooms, backyard, and kitchen. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters were posted. During record review, LPAs observed temperature log for residents. LPA observed facility has a copy of Mitigation Plan on file. LPA observed food, and paper supplies are sufficient.

-At approximately 12:50PM, LPAs were not screed for COVID-19 symptoms and temperature were not checked.

-At approximately 1:25PM, LPAs cabinet drawer in kitchen with a broken lock. Two knives and scissors were accessible in unlocked drawer. One knife was observed accessible in storage area under oven.

-At approximately 1:30PM, LPAs observed broken bike, counter tops, and a patio screen door, located on the deck located the backyard.

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.
Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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: PROFESSIONAL ASSISTED LIVING
FACILITY NUMBER: 079200169
VISIT DATE: 10/22/2021
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Continued from LIC809.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations. Failure to correct deficiencies 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: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2021 03:08 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/22/2021 at 02:24 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: PROFESSIONAL ASSISTED LIVING
FACILITY NUMBER: 079200169

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)(1)
80087 Buildings 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.

(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 in knives and scissors being accessible in a kitchen cabinet drawer with broken lock which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
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Administrator agreed to fix lock on cabinet drawer located in the kitchen and make scissors and knives unacceptable to clients in care. Administrator will submit photo of fixed cabinet drawer to CCLD by POC date. Scissors and knives were made inaccessible during visit.
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) 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 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 in having a broken bike, counter tops, and a patio screen door on the deck in the backyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
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Administrator agreed to remove items from the deck and submit photos to CCLD by POC 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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021


LIC809 (FAS) - (06/04)
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