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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200379
Report Date: 07/16/2025
Date Signed: 07/16/2025 11:37:22 AM

Document Has Been Signed on 07/16/2025 11:37 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 HOMEFACILITY NUMBER:
079200379
ADMINISTRATOR/
DIRECTOR:		ABIGAIL SANTOSFACILITY TYPE:
740
ADDRESS:10061 LA PAZ AVENUETELEPHONE:
(925) 828-9660
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 6DATE:
07/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Caregiver, Marilou AguilarTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 7/16/2025 at 8:00am Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit. Upon arrival, LPA was greeted by Caregiver, Marilou Aguilar. Administrator, was unable to attend and approved caregiver to sign report. 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 70 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 106.2 degrees F. Residents’ shared bathroom is equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/15/2025. Emergency Disaster Plan last updated 7/30/2024. Fire drill was last conducted on 06/30/2025. 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 6 resident records.


report continues on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2025
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/16/2025
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • LPA observed that staff are sleeping in the living room on a cot
  • LPA observed unlocked and unsupervised knives and scissors in the kitchen
  • LPA observed unlocked medications in the kitchen
  • LPA observed multiple expired canned goods
  • LPA observed that facility is limiting R3's use of their hand by placing thick socks over their hand that they cant remove and there is no doctors order.
  • LPA observed that there are not non-slip mats in the residents shower
  • R3 has a restricted health condition

    • 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.
    NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
    NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
    LICENSING PROGRAM ANALYST SIGNATURE:

    		DATE: 07/16/2025
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 07/16/2025
    LIC809 (FAS) - (06/04)
    Page: 3 of 8
    Document Has Been Signed on 07/16/2025 11:37 AM - It Cannot Be Edited


    Created By: Alona Gomez On 07/16/2025 at 10:57 AM
    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: ABIGAIL'S GUEST HOME
    FACILITY NUMBER: 079200379

    DEFICIENCY INFORMATION FOR THIS PAGE:
    VISIT DATE: 07/16/2025

    DEFICIENCIES & PLANS OF CORRECTION (POCs)
    Type A
    Section Cited
    CCR
    87309(a)
    Storage Space and Access
    (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

    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 Knives and scissors being accesable which poses an immediate safety risk to persons in care.
    POC Due Date: 07/16/2025
    Plan of Correction
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    2
    3
    4
    		Staff locked away knives and scissors POC clear
    Type A
    Section Cited
    CCR
    87465(h)(2)
    Incidental Medical and Dental Care Services
    (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
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    2
    3
    4
    		Based on observation, the licensee did not comply with the section cited above in having residents medicines unsecured which poses an immediate safety risk to persons in care.
    POC Due Date: 07/16/2025
    Plan of Correction
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    2
    3
    4
    		Staff locked away medications POC clear
    Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
    Yvonne Flores-Larios
    NAME OF LICENSING PROGRAM MANAGER:
    Alona Gomez
    NAME OF LICENSING PROGRAM ANALYST:
    LICENSING PROGRAM ANALYST SIGNATURE:
    		DATE: 07/16/2025
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 07/16/2025


    LIC809 (FAS) - (06/04)
    Page: 4 of 8
    Document Has Been Signed on 07/16/2025 11:37 AM - It Cannot Be Edited


    Created By: Alona Gomez On 07/16/2025 at 10:57 AM
    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: ABIGAIL'S GUEST HOME
    FACILITY NUMBER: 079200379

    DEFICIENCY INFORMATION FOR THIS PAGE:
    VISIT DATE: 07/16/2025

    DEFICIENCIES & PLANS OF CORRECTION (POCs)
    Type B
    Section Cited
    CCR
    87303(e)(5)
    Maintenance and Operation
    (e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
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    2
    3
    4
    		Based on observation, the licensee did not comply with the section cited above in not having non slip mats in the showerwhich poses a potential safety risk to persons in care.
    POC Due Date: 08/01/2025
    Plan of Correction
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    2
    3
    4
    		By POC facility agrees to purchace and install non-slip mats and notify CCLD
    Type B
    Section Cited
    CCR
    87555(a)
    General Food Service Requirements
    (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
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    2
    3
    4
    		Based on observation, the licensee did not comply with the section cited above having food of poor quality by it being expired which poses a potential health and personal rights risk to persons in care.
    POC Due Date: 08/01/2025
    Plan of Correction
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    4
    		By POC facility agrees to dispose of all expired foods and purchase replacments and notify CCLD
    Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
    Yvonne Flores-Larios
    NAME OF LICENSING PROGRAM MANAGER:
    Alona Gomez
    NAME OF LICENSING PROGRAM ANALYST:
    LICENSING PROGRAM ANALYST SIGNATURE:
    		DATE: 07/16/2025
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 07/16/2025


    LIC809 (FAS) - (06/04)
    Page: 5 of 8
    Document Has Been Signed on 07/16/2025 11:37 AM - It Cannot Be Edited


    Created By: Alona Gomez On 07/16/2025 at 11:13 AM
    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: ABIGAIL'S GUEST HOME
    FACILITY NUMBER: 079200379

    DEFICIENCY INFORMATION FOR THIS PAGE:
    VISIT DATE: 07/16/2025

    DEFICIENCIES & PLANS OF CORRECTION (POCs)
    Type A
    Section Cited
    CCR
    87608(a)(5)
    (a)Based on the individual's preadmission appraisal…(5)Under no circumstances shall postural supports include … limiting the use of a resident's hands or feet.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
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    2
    3
    4
    		Based on observation and interview, the licensee did not comply with the section cited above by limiting R3's use of their hands by having socks over them which poses an immediate personal rights risk to persons in care.
    POC Due Date: 07/18/2025
    Plan of Correction
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    3
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    		By POC facility agrees to remove the restraints and notify 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.
    Yvonne Flores-Larios
    NAME OF LICENSING PROGRAM MANAGER:
    Alona Gomez
    NAME OF LICENSING PROGRAM ANALYST:
    LICENSING PROGRAM ANALYST SIGNATURE:
    		DATE: 07/16/2025
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 07/16/2025


    LIC809 (FAS) - (06/04)
    Page: 7 of 8
    Document Has Been Signed on 07/16/2025 11:37 AM - It Cannot Be Edited


    Created By: Alona Gomez On 07/16/2025 at 11:16 AM
    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: ABIGAIL'S GUEST HOME
    FACILITY NUMBER: 079200379

    DEFICIENCY INFORMATION FOR THIS PAGE:
    VISIT DATE: 07/16/2025

    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 and interview, the licensee did not comply with the section cited above by staff sleeping in the living room which poses a potential personal rights risk to persons in care.
    POC Due Date: 08/01/2025
    Plan of Correction
    1
    2
    3
    4
    		By POC facility agrees to update the caregivers approved room to be able to accommodate staff sleeping and notify CCLD of the update.
    Type B
    Section Cited
    CCR
    87623(a)
    (a)The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances:

    This requirement is not met as evidenced by:
    Deficient Practice Statement
    1
    2
    3
    4
    		Based on observation and interview, the licensee did not comply with the section cited above in R3 having a catheter which they try ripping out when unsupervised which poses a potential safety risk to persons in care.
    POC Due Date: 08/01/2025
    Plan of Correction
    1
    2
    3
    4
    		By POC facility will discuss alternative solutions with the responsible parties and notify CCLD of the plan.
    Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
    Yvonne Flores-Larios
    NAME OF LICENSING PROGRAM MANAGER:
    Alona Gomez
    NAME OF LICENSING PROGRAM ANALYST:
    LICENSING PROGRAM ANALYST SIGNATURE:
    		DATE: 07/16/2025
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 07/16/2025


    LIC809 (FAS) - (06/04)
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