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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200296
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:51:17 PM


Document Has Been Signed on 02/18/2022 03:51 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:ALAMO RESIDENCE HOME, INC.FACILITY NUMBER:
079200296
ADMINISTRATOR:NANCY CHIHWAN OHFACILITY TYPE:
740
ADDRESS:2978 MIRANDA AVENUETELEPHONE:
(925) 837-0521
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: DATE:
02/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Nancy Oh, LicenseeTIME COMPLETED:
04:05 PM
NARRATIVE
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On 2/17/2022 at 1:10 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen conducted a Case Management while at the facility for a complaint (CN# 15-AS-20210526105438). LPAs met with Administrator, Joy Manalang and explained the purpose of the visit. Licensee, Nancy Oh later arrived at 2:13 PM.

During the visit, LPA observed R1's medication log for morphine was not being maintained at the facility. S1 stated notebook was given to R1's responsible party on May 11, 2021.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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 02/18/2022 03:51 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: ALAMO RESIDENCE HOME, INC.
FACILITY NUMBER: 079200296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2022
Section Cited

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RESIDENT RECORDS
(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
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Based on record review, Licensee did not comply with the regulation cited above. LPA observed medication notebook is not being maintained at facility which poses a potential health and safety risk to residents in care.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
LIC809 (FAS) - (06/04)
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