079200242-2-15-2023-15-AS-LIBO-CP3UUJ-20230215145337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200242
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:53:56 PM

Document Has Been Signed on 02/15/2023 02:53 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:	CICADA-LAUREL		FACILITY NUMBER:	079200242
ADMINISTRATOR:	DEBORAH COX,MARISA MCBRIDE		FACILITY TYPE:	735
ADDRESS:	2145 CONNIE LANE		TELEPHONE:	(415) 412-5851
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY: 6		CENSUS: 6	DATE:	02/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Lira Reyes, staff		TIME COMPLETED:	03:15 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 02/15/2023 at 9:55AM, Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and met with S2, LPA called Administrator(S1) and explained the purpose of the visit. LPA observed 1 client during the visit and other clients are at the day program. Facility has a completed mitigation plan and copy of infection control plan was received. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. Facility pool was observed to locked and inaccessible to clients in care. Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 70 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational. The facility is being manage by S2, according to S1 stated that they changed administrator and made S2 as Administrator. LPA requested for proof of change of Administrator to be sent to CCL by 02/20/2023. …Continue to LIC809C…

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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 7

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: CICADA-LAUREL	FACILITY NUMBER: 079200242
	VISIT DATE: 02/15/2023

NARRATIVE

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LPA observed the following:
· At 10:37AM LPA observed unlocked disinfectants accessible to clients in care
· At 10:36AM LPA observed unlocked medication cabinet accessible to clients in care
· At 10:38AM LPA observed mold fruits at the pantry and expired canned goods.
· At 10:40AM LPA observed unlocked pair of scissors and knife at the kitchen drawer
· At 10:44AM LPA observed that fireplace do not have barrier which was accessible to clients in care.
· At 10:56AM LPA observed that the sliding door going outside to the backyard was stuck and staff must forcefully push it for it to be fully open.
· Based on document reviewed LPA observed that facility sketch stated that bedroom #4 lower level was labeled as staff room but licensee is using it as clients shared bedrooms.

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.

Deficiencies and plan and proof of corrections were discussed with S3, staff

Exit interview conducted and appeal rights copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 02/15/2023 02:53 PM - It Cannot Be Edited

Created By: Leslie Ibo On 02/15/2023 at 12:37 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: CICADA-LAUREL	FACILITY NUMBER: 079200242
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

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 in failed to maintain sliding door in good repair at all times which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/03/2023
	Plan of Correction
1 2 3 4	Administrator agreed to repair the sliding door. Administrator will hire someone to repair the sliding door, a proof of job order or correction will need to be sent to CCL by POC date.

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in fauled to cover the fireplace at the living room area which was accesible to clients in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/03/2023
	Plan of Correction
1 2 3 4	Administrator agreed to repair the 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.

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: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 02/15/2023 02:53 PM - It Cannot Be Edited

Created By: Leslie Ibo On 02/15/2023 at 12:37 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: CICADA-LAUREL	FACILITY NUMBER: 079200242
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80076(a)(1)

Food Service

(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner. 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, staff failed to remove molded fruits, rotten vegetables, and expired goods at the pantry which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed that staff will remove all the expired food supplies at the facility and throw away all the molded fruits and vegetables. An inservice training for all staff is needed to discuss the cited regulation above. Administrator will submit of proof of training with staff names, staff signatures and copy of training topics that was use.

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:

Harpreet Humpal

LICENSING EVALUATOR NAME:

Leslie Ibo

LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 02/15/2023 02:53 PM - It Cannot Be Edited

Created By: Leslie Ibo On 02/15/2023 at 12:42 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: CICADA-LAUREL	FACILITY NUMBER: 079200242
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)(1)

(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
1 2 3 4	Based on observation the licensee did not comply with the section cited above in failed to lock disinfectant, pair of scissors and knives which was accisble to clients in care,which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2023
	Plan of Correction
1 2 3 4	cleared and corrected. Staff locked the items.

Type A

Section Cited

CCR

80075(k)(1)

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 unlocked medications which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/15/2023
	Plan of Correction
1 2 3 4	S2 locked the medication refrigerator. Administrator agreed to conduct in-service training with all the staff. Proof of training with staff names, signature and copy of training topic needs to be submitted to CCL by 03/02/2023.

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: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 02/15/2023 02:53 PM - It Cannot Be Edited

Created By: Leslie Ibo On 02/15/2023 at 01:02 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: CICADA-LAUREL	FACILITY NUMBER: 079200242
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80065(f)(5)

Personnel Requirements

(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in, adminsitrator failed to show proof of covid19 training for all staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/03/2023
	Plan of Correction
1 2 3 4	Administrator agreed to send proof of covid19 training to CCL by 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:

Harpreet Humpal

LICENSING EVALUATOR NAME:

Leslie Ibo

LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 02/15/2023 02:53 PM - It Cannot Be Edited

Created By: Leslie Ibo On 02/15/2023 at 02:42 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: CICADA-LAUREL	FACILITY NUMBER: 079200242
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation and records review, licensee failed to follow facility sketch where clients are using staff bedroom #4 lower level (room number based on facility sketch) and staff have been using bedroom #1 upper level.
	POC Due Date: 02/17/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator states that she will move two clients on bedroom #1 upper level based on facility sketch. Administrator stated that she plans to call fire department to update the facility sketch and facility fire clearance.

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:

Harpreet Humpal

LICENSING EVALUATOR NAME:

Leslie Ibo

LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 7 of 7