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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200342
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:46:17 PM

Document Has Been Signed on 05/16/2024 03:46 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:REGINA HAVENFACILITY NUMBER:
079200342
ADMINISTRATOR/
DIRECTOR:		MELISSA LIPARDOFACILITY TYPE:
735
ADDRESS:4621 REGINA LANETELEPHONE:
(650) 483-7269
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Bernadette Aguila, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 05/16/2024 at 10:35 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Bernadette Aguila and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) Ambulatory. Administrator's Certificate # 6060171735 expires 07/01/2025.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 3 bedrooms are occupied by the clients and 2 bedrooms is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathrooms was measured at 116.2 and 120 degrees Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene supplies were available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/06/2023. Emergency Disaster Drill was last posted on 01/15/2024. First aid kit was observed to be complete. Fire and earthquake drills was last conducted on 04/08/2024.

5 of 5 clients’ records were reviewed. Eleven (11) staff records were reviewed, and 11 of 11 have current first aid training and associated to the facility. A sample of one (1) client’s medications were reviewed.

LIC809-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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 05/16/2024 03:46 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/16/2024 at 02:56 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: REGINA HAVEN
FACILITY NUMBER: 079200342

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

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

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 in by having yard with clutter which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Administrator will remove and clean up the clutter in the yard. Submit photo to CCLD by POC due date.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

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 in by having updated Appraisal Needs and Services (ANS) for each Client (C1-C5) last done 2020, C3 was missing an ANS which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Administrator agrees to update ANS for each client and send copies to CCLD by POC due date.
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:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: REGINA HAVEN
FACILITY NUMBER: 079200342
VISIT DATE: 05/16/2024
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LIC809-C Continued....

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.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 2:30PM LPA observed mattress, computer monitor, fan, car door panel, broken chair, several garbage bags located outside back yard

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 05/23/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan - Reviewed

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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