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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200240
Report Date: 03/26/2024
Date Signed: 03/26/2024 05:29:56 PM

Document Has Been Signed on 03/26/2024 05:29 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
OAKLAND ASC, 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:
03/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Mariejoy Bebura CaregiverTIME COMPLETED:
05:35 PM
NARRATIVE
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On 03/26/2024 at 2:25pm, Licensing Program Analysts (LPA's) T. Syess-Gibson and L. Hall conducted an unannounced annual 1-year required inspection. LPAs met with Mariejoy Bebura Caregiver, and explained the purpose of the visit. Administrator, Cyntia Ramirez Del Rio, arrived at 2:45pm.The facility’s fire clearance was approved for six (6) non ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard no bodies of water present. The facility consists of five (5) total bedrooms and two (2) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. A comfortable temperature for clients is maintained at 68 degrees Fahrenheit. LPAs 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 99.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last service on 09/12/2023. Fire drill last conducted 02/27/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FERNWOOD RESIDENTIAL CARE
FACILITY NUMBER: 079200240
VISIT DATE: 03/26/2024
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Continued from LIC809.

Four (4) staff records were reviewed, and all staff have first aid certification. All Five (5) clients' records reviewed, current, and complete. LPAs reviewed P&I and a sample of medications.

The following forms to be updated and submitted to CCLD by 04/02/2024
  • Liability insurance.
  • Surety Bond
  • LIC500 (Updated)
  • LIC610D (9 pages)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources

LPAs observed the following deficiencies:

At 2:25PM Screen on front door is in disrepair
At 2:35PM Patio door and three (3) bedroom windows missing screens
At 2:36 PM Bedrooms broken bedroom window

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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2024 05:29 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/26/2024 at 04:27 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: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
80088 Furniture, Fixtures, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris

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 not having screens in good repair on front door and windows. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Administrator agrred to replace screen(s) and submit photos via email to CCLD by POC date.
Type B
Section Cited
CCR
80087(a)
(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 windiw in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Adminsitrator agrred to have window repaired and submit a picture via email 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
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