079200197-4-25-2024-15-AS-KNGN-D4NT3H-20240425142222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200197
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:22:34 PM

Document Has Been Signed on 04/25/2024 02:22 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:	FUTURE COLOURS CORP		FACILITY NUMBER:	079200197
ADMINISTRATOR:	RAMONA RACHITA		FACILITY TYPE:	735
ADDRESS:	1579 N. MITCHELL CANYON ROAD		TELEPHONE:	(925) 672-8173
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	6	CENSUS: 6	DATE:	04/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Martella Walker, Staff Member		TIME COMPLETED:	02:40 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 4/25/2024 at 9:50 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with staff Martella Walker, LPA spoke with Administrator (AD), Rachita Ramona over the phone and explained the purpose of the visit. AD stated that she was not able to attend and gave verbal permission for staff Martella to sign the report. The facility’s fire clearance was approved for 6 Ambulatory. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. 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 107.4 degree Fahrenheit in bathroom 1 and 106.9 degree Fahrenheit in bathroom 2. All toilets, hand washing, and bathing 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 7/17/2023. Emergency Disaster Drill was last posted on 3/16/2023. First aid kit was observed to be complete. Report continues on 809 C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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 04/25/2024 02:22 PM - 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: FUTURE COLOURS CORP	FACILITY NUMBER: 079200197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(e)(1)

Building and Grounds

(e) All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence. (1) Fences shall be at least five-feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use. 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 the pool gate unlock, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Staff locked up the pool gate during inspection- Deficiency cleared

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) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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: FUTURE COLOURS CORP	FACILITY NUMBER: 079200197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

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 by having cleaning unlock in the closet next to the from entreance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Staff put away the cleaning supply and locked during inspection- Deficiency cleared

Type A

Section Cited

CCR

80087(h)

Building and Grounds

(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above. 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 meication in a zip lock bag left on the kitchen counter unlock, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Staff put away medicine and locked- Deficiency cleared

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) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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: FUTURE COLOURS CORP	FACILITY NUMBER: 079200197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. 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 emergency exit outside on the porch have multiples exercises equipment’s that are blocking the pathway of the emergency exit. On the side next to the exit door wooden gate there are a pile of mattress that are stacking on top of each other, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Administrator will submit photo to CCLD of the removal of the mattress and clear the porch that is blocking the emergency pathway by the 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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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: FUTURE COLOURS CORP	FACILITY NUMBER: 079200197
	VISIT DATE: 04/25/2024

NARRATIVE

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At 12:00 PM, 5 of clients’ records were reviewed. At 1:00 PM, 2 staff records were reviewed, and 2 of 2 have current first aid training and associated to the facility. A sample of 3 client’s medications were reviewed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/1/2024:

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

LPA observed the following deficiencies:

11:05am: LPA observed cleaning chemical left unlock in closet near the front entrance door. Staff locked chemical- Deficiency cleared.

11:15am: LPA observed emergency exit outside on the porch have multiples exercises equipment’s that are blocking the pathway of the emergency exit. On the side next to the exit door wooden gate there are a pile of mattress that are stacking on top of each other.

11:30am: LPA observed the lock on the pool gate was left unlock. (Civil Penalty Assess, Immediate $500 was issue on 4/25/24)- Staff locked pool gate- Deficiency Cleared

11:45am: LPA observed medication that are left unlock on kitchen counter inside zip lock bag. -Staff locked medication- Deficiency cleared

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

Exit interview conducted with staff Martella Walker . A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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