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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200321
Report Date: 09/19/2022
Date Signed: 09/19/2022 04:26:33 PM

Document Has Been Signed on 09/19/2022 04:26 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:BRADY'S HOME, THEFACILITY NUMBER:
079200321
ADMINISTRATOR:CECILIA HAWKINSFACILITY TYPE:
735
ADDRESS:2401 FAIRFIELD AVENUETELEPHONE:
(925) 686-2996
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 6CENSUS: 6DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Annabelle Lacusong, CaregiverTIME COMPLETED:
04:50 PM
NARRATIVE
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On 09/19/2022 at 2:00 pm, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Annabelle Lacusong and explained the purpose of the visit. Administrator arrived at approximately 4:10pm.

Upon entry, LPA temperature were checked by staff. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitors log and temperature logs for residents and staff. LPA observed facility has a copy of Mitigation Plan on file.

The following deficiencies were observed during the visit:
-At 2:14pm, LPA observed unlocked scissors in office area.
-At 2:16pm LPA observed paint under the bathroom sink.
-At 2:18pm LPA observed WD-40, Bug & Tar remover.
-At 2:21pm, LPA observed 2 lighters unlocked in a kitchen drawer
-At 2:22pm, LPA observed unlocked cleaning supplies, Comet, 409 spray.
-At 2:28pm, LPA observed a ladder unlocked on the upstairs deck.
-At 2:29pm, LPA observed a bedframe, headboard, fax machine, recycling, dresser, chairs and night stand located in the backyard.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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 09/19/2022 04:26 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/19/2022 at 03:52 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: BRADY'S HOME, THE
FACILITY NUMBER: 079200321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(g)
80087 Buildings 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.
(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.

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 by having scissors, paint, WD-40, Bug & Tar Remover, 2 lighters, Comet, 409 spray, ladder, bedframe and headboard dresser, chairs, and night stand accessible to clients which poses a potential health and safety risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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Administrator will conduct training with staff on the importance of keeping sharp objects and chemicals locked and inaccessible to clients in care and provide a signed attendance sheet to CCLD no later then the POC date.

Administrator will remove the ladder, bedframe and headboard, dresser, chairs and night stand and provide photo copies to CCLD no later then the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022


LIC809 (FAS) - (06/04)
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