079200315-5-23-2022-15-AS-LIBO-CEPRBQ-20220523125307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200315
Report Date: 05/23/2022
Date Signed: 05/23/2022 12:53:38 PM

Document Has Been Signed on 05/23/2022 12:53 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:	MONTESSORI SENIOR RESIDENTIAL CARE		FACILITY NUMBER:	079200315
ADMINISTRATOR:	PAMELA ZELL RIGG		FACILITY TYPE:	740
ADDRESS:	3431 BALFOUR ROAD		TELEPHONE:	(925) 516-2111
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 5	DATE:	05/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Ruth Cabral, Assistant Administrator		TIME COMPLETED:	01:10 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 5/23/2022 at 10:15 AM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Assistant Administrator Ruth Cabral. LPA called licensee Pamela Rigg to inform her the purpose of the visit, licensee stated that Administrator Shaku Chhagan is not available. Licensee gave permission to LPA to discuss and give copy of the report to Assistant Administrator. LPA inspected the facility inside and outside. Pool was properly secured and locked. Pathways were observed to be free of obstruction and fire hazards. Infection control designated leader is the Administrator. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Facility staff were observed to be wearing proper PPE (mask). Facility has a mitigation plan and maintains record of routine screening for residents and staff. Facility has enough supplies of, paper supplies and hygiene supplies. …Continued on LIC809C…

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

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 3

Document Has Been Signed on 05/23/2022 12:53 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: MONTESSORI SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 079200315
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 kitchen faucet is not in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2022
	Plan of Correction
1 2 3 4	Staff (Ruth Cabral) stated that she will let Administrator know that kitchen faucet needs to either replace or fix. LPA asked for picture showing kitchen faucet is fix or service 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: MONTESSORI SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 079200315
	VISIT DATE: 05/23/2022

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

Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 72 degrees Fahrenheit. Water temperature was checked and observed to be at 116.5 degrees Fahrenheit. Fire extinguisher was observed to be fully charged with last service date of September 2021. 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.

LPA observed the following:

· Kitchen faucet is not in good repair
· LPA observed that visitor/health care professional was not screened before attending to resident in care. LPA discussed this issue with Assistant Administrator Ruth Cabral. (technical assistance provided)
· Facility need at least 30-days of PPE supplies available at the facility. LPA asked staff to send picture of 30-days PPE supplies.

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 Ruth Cabral

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3