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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200240
Report Date: 03/24/2023
Date Signed: 03/24/2023 01:31:46 PM

Document Has Been Signed on 03/24/2023 01:31 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:FERNWOOD RESIDENTIAL CAREFACILITY NUMBER:
079200240
ADMINISTRATOR:FRED PARR COX IIIFACILITY TYPE:
735
ADDRESS:1676 FERNWOOD DRIVETELEPHONE:
(925) 625-7312
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 5DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Cynthia Ramirez, new Administrator TIME COMPLETED:
01:45 PM
NARRATIVE
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On this day 03/24/2023 at around 9:20AM, Licensing Program Analyst (LPA) L. Ibo arrived at the facility to conduct annual required inspection. LPA was met by new Administrator Cynthia Ramirez the current Administrator on file Fred Parr Cox III was not available during the visit. LPA explained the purpose of the visit with Cynthia and Fred C. was also informed of the purpose of the visit.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, garage dining and living areas. The facility has 5 bedrooms and 2 bathrooms. One bedroom is designated as activity room. There were 2 clients observed and around 12:30PM 2 clients came back from their day program. Facility has an approved fire clearance for 6 non ambulatory clients. Two fire extinguishers that was serviced on Sept. 9, 2022.

Facility has sufficient supply of perishable and non-perishable foods. There were 4 staff working during the visit and both are fingerprint cleared. Bathrooms were observed with grab bars and nonskid mats.

LPA reviewed 2 clients and 3 staff files and attempted to interview 2 clients. LPA interviewed 3 staff. Facility has wired carbon monoxide and smoke detector that were observed functional. Facility has a current liability insurance.

LPA observed the following:
At approximately 9:28AM, LPA observed unlocked medications at the cabinet adjacent to the living room.
At approximately 9:30AM, LPA observed living room fireplace was not covered.
At approximately, 10:01AM, LPA observed facility do not have night lights.
At approximately 11:30AM, Records review revealed that facility sketch plan stated that bedroom #2 or masters bedroom indicated it is for Staff only, however STD850 stated that all rooms behind the hall door can be used for clients in care. ...CONTINUE TO LIC809C..
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 03/24/2023 01:31 PM - It Cannot Be Edited


Created By: Leslie Ibo On 03/24/2023 at 11:24 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: FERNWOOD RESIDENTIAL CARE
FACILITY NUMBER: 079200240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation the licensee did not comply with the section cited above in staff failed to lock medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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Cleared and corrected during visit.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/24/2023 01:31 PM - It Cannot Be Edited


Created By: Leslie Ibo On 03/24/2023 at 11:24 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: FERNWOOD RESIDENTIAL CARE
FACILITY NUMBER: 079200240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

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 licensee failed to cover the fireplace and it was accesible to clients in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Administrator agreed to repair fireplace door or cover. Administrator will hire someone to repair or place a fireplace cover, a proof of job order or correction will need to be sent to CCL by POC date. Administrator agreed to send a picture of the fireplace by POC date.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in licensee failed to maintain nightlights in the hallways and nonprivate bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2023
Plan of Correction
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Administrator agreed to place nightlights on the hallways and nonprivate bathrooms. A pictures on the nightlights need to send to CCL office 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/24/2023 01:31 PM - It Cannot Be Edited


Created By: Leslie Ibo On 03/24/2023 at 12:57 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: FERNWOOD RESIDENTIAL CARE
FACILITY NUMBER: 079200240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(b)(7)
A sketch of the building(s) to be occupied, including a floor plan which describes the capacities of the buildings for the uses intended.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, licensee failed to update facility sketch where masters bedroom indicated that it is for staff only, however STD850 stated that it’s ok to occupy bedrooms behind the hall door which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Administrator agreed to send an updated facility sketch 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023


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: FERNWOOD RESIDENTIAL CARE
FACILITY NUMBER: 079200240
VISIT DATE: 03/24/2023
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC809 (FAS) - (06/04)
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