079200169-8-8-2024-15-AS-CFOR-D7XLUG-20240808090352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200169
Report Date: 07/10/2024
Date Signed: 08/08/2024 09:05:07 AM

Document Has Been Signed on 08/08/2024 09:05 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:	PROFESSIONAL ASSISTED LIVING		FACILITY NUMBER:	079200169
ADMINISTRATOR:	RAY LANGIT,DARLENE ATIZADO		FACILITY TYPE:	735
ADDRESS:	852 CORAL DRIVE		TELEPHONE:	(510) 245-7234
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY:	6	CENSUS: 6	DATE:	07/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	LORNA NIDEA, CAREGIVER		TIME COMPLETED:	02:00 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	Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-year required visit on 7/10/2024 at 9:30am. LPA met and toured with Caregiver, Lorna Nidea. LPA later met with Administrator, Darlene Atizado at 10:40am. The Administrator currently holds a certificate (#6023419735) that expires on 12/16/2022. The facility’s fire clearance was approved for 6 clients, which all may be ambulatory. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 3 bedrooms are occupied by the clients and 2 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA 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 133 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/5/2023. Emergency Disaster Plan was last posted on 08/29/2019. First aid kit was observed to be complete. LPA reviewed 4 staff record files. 4 of 4 staff have criminal record clearance or a criminal record exemption and holds a current first aid certificate. LPA reviewed 4 clients' files and P & I money. Based on interview, Facility handles 4 clients P & I money, which 2 clients P & I money is handled in a bank account. Report continues on 809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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 08/08/2024 09:05 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a knife in an unlocked drawer in the kitchen which poses an immediate health and safety to persons in care.
	POC Due Date: 07/11/2024
	Plan of Correction
1 2 3 4	Administrator agreed to keep all sharps locked at all times. DEFICIENCY CLEARED DURING VISIT.

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, 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, the licensee did not comply with the section cited above in having the water temperature at 133 degrees which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/11/2024
	Plan of Correction
1 2 3 4	Administrator agreed to test a water sample monthly and keep water temperature between 105 and 120 degrees. DEFICIENCY CLEARED DURING VISIT.

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	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2024 09:05 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having a refrigerator with repairs needed which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/31/2024
	Plan of Correction
1 2 3 4	Administrator has an appointment for the refrigerator repair and will submit a copy of the invoice to the department by the POC date.

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation record review, the licensee did not comply with the section cited above by not conducting quarterly drills which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Administrator agree to conduct an disaster drill by the POC date and submit information to the department by the 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	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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: 07/10/2024

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LPA observed following deficiencies:
- at 10:00am. LPA observed a knife located in an unlocked drawer.
- at 10:07am. refrigerator ice maker needs repair.
-at 10:10am LPA observed fire drill was last conducted on 06/8/2021.

The following forms to be updated and submitted to CCL by 7/14/2024:

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 610E Emergency Disaster Plan

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

LIC809 (FAS) - (06/04)

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