<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200242
Report Date: 03/09/2024
Date Signed: 03/09/2024 02:49:43 PM

Document Has Been Signed on 03/09/2024 02:49 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-LAURELFACILITY NUMBER:
079200242
ADMINISTRATOR:DEBORAH COX,MARISA MCBRIDEFACILITY TYPE:
735
ADDRESS:2145 CONNIE LANETELEPHONE:
(415) 412-5851
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
03/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Oscar Magno, Direct CareTIME COMPLETED:
03:00 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
On 3/9/2024 at 12:10pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Oscar Magno, Direct Care and explained the purpose of the visit. LPA spoke with administrator, Patti Inouye, via telephone. The administrator currently holds a certificate (#6011697730) that expires on 8/19/2024. The facility’s fire clearance was approved for four (4) ambulatory and two (2) non-ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of seven (7) bedrooms and three(3) bathrooms. Two (2) bedrooms occupied by staff. All indoor passageways are kept free of obstruction. Swimming surround by metal gate and is locked with padlock. A comfortable temperature for clients is maintained at 75 degrees 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 107.7 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, 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 services on 1/29/2024. Fire drill last conducted 11/6/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2024
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
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: 03/09/2024
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
26
27
28
29
30
31
32
Continued from LIC809.

Four (4) staff records were reviewed all were current and complete. All six (6) client's records were reviewed and complete. LPA also reviewed P & I.

The following forms to be updated and submitted to CCLD by 3/18/2024:
  • LIC610D Emergency disaster plan (9 pages)
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • Administrative organization
  • LIC400 Affidavit Regarding Client/Resident Cash Resources
  • Surety Bond


The following deficiencies were observed:
  • At 12:45pm, LPA observed during record review that four (4) of six (6) clients did not have an accurate record of their cash resource.
  • At 1:35pm, LPA observed medication in unlocked cabinet in kitchen covered by a towel.
  • At 1:45pm, LPA observed downstairs shared bathroom shower has broken tile on floor.
  • At 1:50pm, LPA observed a bed frame sitting on a futon couch in the upstairs hallway.
  • At 1:55pm, LPA observed no screen on patio door, and bedroom #4 window screen in disrepair.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 03/09/2024
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
26
27
28
29
30
31
32
Continued from LIC809C.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/09/2024 02:49 PM - It Cannot Be Edited


Created By: Laura Hall On 03/09/2024 at 02:23 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: 03/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(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 inhaving medication inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2024
Plan of Correction
1
2
3
4
The Direct Care Support locked medication in medicine closet immediately. Deficiency cleared during visit.
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/09/2024 02:49 PM - It Cannot Be Edited


Created By: Laura Hall On 03/09/2024 at 02:23 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: 03/09/2024

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 in having the tile in shared shower downstairs in repair, screens on patio and bedroom 4 window, and bedframe on futon in upstairs hallway which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
1
2
3
4
Administrator agreed to have screens replaced, bed frame removed, and tile in shower repaired and submit photos to CCLD by POC date.
Type B
Section Cited
CCR
80026(h)(1)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having cash resources ledger accurate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
1
2
3
4
Administrator agreed to update cash resource ledger and submit copy 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5