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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200334
Report Date: 02/24/2021
Date Signed: 02/24/2021 04:06:35 PM

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:AMAZING HOME CARE IIFACILITY NUMBER:
079200334
ADMINISTRATOR:MARILOU SOLOMONFACILITY TYPE:
740
ADDRESS:5017 SAINT GARRETT COURTTELEPHONE:
(925) 671-7909
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
02/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Almarie SolomonTIME COMPLETED:
09:14 AM
NARRATIVE
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On 2/24/21 at 8:56am LPA Jacob Williams conducted an unannounced case management visit regarding deficiencies that were identified while reviewing a separate matter. Due to the State’s current shelter-in-place order, the visit was conducted via telephone.

While reviewing the separate matter, it was determined that in 2015 S1 and S3 had knowledge of the possibility that S5 was engaging in an inappropriate relationship with R1. S3 is the spouse of the Licensee and had supervisory responsibility for the facility. S3 acknowledged to the investigator that an SOC341 and Incident Report had not been made and submitted.

The Department was informed by the facility that S4 has been working at the facility since 2018, however, it was found that S4 is not fingerprint cleared and associated. An immediate civil penalty was assessed.

It was further determined that S2 and S3 are acting as “Administrators” on behalf of the Licensee. The Department found that neither the Licensee, S2 or S3 have active Administrator certificates.

Deficiencies are per California Code of Regulations, Title 22. Failure to submit plan of correction by due date by result in additional civil penalties.

Exit interview conducted and a copy of this report and Appeal Rights were provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
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
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: AMAZING HOME CARE II
FACILITY NUMBER: 079200334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2021
Section Cited

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...All employees…subject to a criminal record review shall…Obtain a California clearance.

This requirement is not met as evidenced by:
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 IB investigator and LPA found that S4 has been working at facility since 2018 without criminal record clearance, which is an immediate threat to health and safety of residents in care.
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Type B
03/08/2021
Section Cited

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Each licensee shall furnish to the licensing agency such reports as a written report...within 7 days of the occurance of... Any incident which threatens the welfare, safety or health of any resident.
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This requirement was not met as evidenced by: IB found that facility didn't report possible inappropriate relationship between R1 & S5, which is a potential threat to the health and safety of residents.
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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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2021
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: AMAZING HOME CARE II
FACILITY NUMBER: 079200334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2021
Section Cited

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All facilities shall have a qualified and currently certified administrator.

This requirement was not met as evidenced by:
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IB investigator and LPA were informed that Licensee has not been at facility since August 2019 and that S1 & S2 have been handling Administrator duties without having active Administrator Certificates.
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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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3