079200379-6-13-2024-15-AS-AGOZ-D683P3-20240613182452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200379
Report Date: 06/13/2024
Date Signed: 06/13/2024 06:25:00 PM

Document Has Been Signed on 06/13/2024 06:25 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
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: 4	DATE:	06/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Caregiver, Kevin Sobritchea		TIME COMPLETED:	06:45 PM

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	On 6/13/2024 at 3:30pm Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit. Upon arrival, LPA was greeted by Caregiver, Kevin Sobritchea. Backup Administrator, James Santos arrived at 4:00pm. The facility's fire clearance was approved for all may be non-ambulatory LPA toured the facility with Backup Administrator 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 73 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 106.3 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 02/09/2024. Emergency Disaster Plan last updated 7/22/2023. Fire drill was last conducted on 05/17/2024. First aid kit was observed complete. LPA reviewed 2 staff records and 2 of 2 staff are associated and have first-aid training. LPA reviewed 4 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: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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: 06/13/2024

NARRATIVE

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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

LPA observed that there was only staff on schedule and some residents needs and services state that they require 1:1 assistance throughout the day with activities.

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.

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: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/13/2024 06:25 PM - 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: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(4)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in only having 1 staff on duty when 2 residents needs and services state they need 1:1 assistance with specific tasks which poses a potential safety risk to persons in care.
	POC Due Date: 06/13/2024
	Plan of Correction
1 2 3 4	Administrator states they will stay on duty and also call in more staff.

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: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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