079200379-1-26-2024-15-AS-AGOZ-CZUQXB-20240126113316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200379
Report Date: 01/26/2024
Date Signed: 01/26/2024 11:33:25 AM

Document Has Been Signed on 01/26/2024 11:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	ABIGAIL'S GUEST HOME		FACILITY NUMBER:	079200379
ADMINISTRATOR:	ABIGAIL SANTOS		FACILITY TYPE:	740
ADDRESS:	10061 LA PAZ AVENUE		TELEPHONE:	(925) 828-9660
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 5	DATE:	01/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Caregiver, Marilou Aguilar		TIME COMPLETED:	11:45 AM

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	Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit on this date starting at 9:00am. Upon arrival, LPA was greeted by Caregiver, Marilou Aguilar. Administrator was not available during visit. The facility's fire clearance was approved for all may be non-ambulatory LPA toured the facility with Caregiver including but not limited to the bedrooms, bathrooms, kitchen, common areas, and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 69 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111.6 degrees F. Residents’ shared bathroom is equipped with grab bars and non-skid mat. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/07/2023. Emergency Disaster Plan last updated 7/22/2023. Fire drill was last conducted on 09/08/2023. First aid kit was observed complete. LPA reviewed 3 staff records and 3 of 3 staff are associated and have first-aid training. LPA reviewed 5 resident records. report continues on LIC809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ABIGAIL'S GUEST HOME	FACILITY NUMBER: 079200379
	VISIT DATE: 01/26/2024

NARRATIVE

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The following deficiencies were observed during visit:

At 9:00am upon arrival LPA observed a roll out bed with bedding in living room. Caregiver stated that they used it to sleep on. Caregiver removed bed during visit. Deficiency cleared
At 11:01 during tour LPA observed walk way/ fire exit outside blocked (door leading outside from room 1 is inaccessible.)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/26/2024 11:33 AM - 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ABIGAIL'S GUEST HOME	FACILITY NUMBER: 079200379
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: 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 care staff having a bed for sleeping in living room which poses/posed a potential personal rights risk to persons in care.
	POC Due Date: 01/26/2024
	Plan of Correction
1 2 3 4	Caregiver removed bed durring visit.

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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 01/26/2024 11:33 AM - 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ABIGAIL'S GUEST HOME	FACILITY NUMBER: 079200379
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a fire exit blocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to clear fire exit and submit photographic proof to CCLD

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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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