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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200334
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:41:04 AM

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: DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator, Almarie Solomon TIME COMPLETED:
10:50 AM
NARRATIVE
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On 11/22/2021 at 08:50 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Administrator Almarie Solomon and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan.

The following deficiency was observed during the visit:
-At 8:55AM, LPA during record review, LPA observed that S1 and S2 are not associated with the facility.
-At 9:05AM, LPA observed unlocked knives and scissors in the kitchen.
-At 9:10AM, LPA observed lawn mower and a metal frame obstructing the pathway in the backyard.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA observed S1 and S2 is cleared, however, not associated to facility which poses a potential health and safety risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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By POC, Administrator will review regulation and submit self-certification letter to CCL.

LPA observed staff was removed from facility.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 unlocked knives which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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The facility will fix the drawer or relocate the knives to a secure drawer.
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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021
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: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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. LPA observed lawn mower and a metal frame blocking the backyard gate.
POC Due Date: 11/23/2021
Plan of Correction
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Deficiency cleared during visit. LPA observed staff remove metal frame and moved the lawn mower.

DEFICIENCY CLEARED
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3