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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200398
Report Date: 11/26/2024
Date Signed: 11/26/2024 05:58:34 PM

Document Has Been Signed on 11/26/2024 05:58 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:DONCASTER HOUSEFACILITY NUMBER:
079200398
ADMINISTRATOR/
DIRECTOR:		ESPINO, ALBERTFACILITY TYPE:
735
ADDRESS:1001 DONCASTER AVETELEPHONE:
(925) 779-1830
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 5DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Albert Espino AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:10 PM
NARRATIVE
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On 10/26/2024 at 1:20 PM, Licensing Program Analysts (LPAs) D. Doidge and L. Hall conducted an unannounced annual 1-year required inspection. LPAs met with Albert Espino, Administrator, and explained the purpose of the visit. The administrator currently holds a certificate (#6061533735) that expires on 11/14/2025. The facility’s fire clearance was approved for six (6) non-ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of six (6) total bedrooms and two (2 ) bathrooms. Three (3) bedrooms are occupied by staff. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 111.degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/30/2024. Fire drill last conducted 11/17/2024. Emergency Disater Plan last updated on 11/15/2024. First aid kit was observed to be complete.

Six (6) staff records were reviewed, and all staff have first aid certification. All five (5) client records were reviewed, current, and completed. LPAs reviewed P & I and a samples of medications.

Continued on LIC809-C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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: DONCASTER HOUSE
FACILITY NUMBER: 079200398
VISIT DATE: 11/26/2024
NARRATIVE
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 12/05/2024.
  • LIC610D Emergency disaster plan.
  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources


LPAs observed the following deficiencies:
  • At 1:20 PM, LPAs observed facility did not have a 7 day supply of non-perishables and two day perishables.

  • At 1:25 PM, LPAs observed toilet bowl cleaner and deodorizer spray in shared bathroom.

  • At 1:45 PM, LPAs observed Bono, 7 cans of deodorizer spray, and floor cleaner in unlocked hall closet.

  • At 1:55 PM, LPAs observed backyard unlocked shed with weed killer.

  • At 2:00 PM, LPAs observed in backyard a futon cushion, Sheetrock piece of wood, broken chair, and broken bench.


Continued on LIC809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DONCASTER HOUSE
FACILITY NUMBER: 079200398
VISIT DATE: 11/26/2024
NARRATIVE
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Continued from LIC809-C
  • At 2:05 PM LPAs, observed a broken patio screen door.

The following deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 05:58 PM - It Cannot Be Edited


Created By: David Doidge On 11/26/2024 at 05:04 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: DONCASTER HOUSE
FACILITY NUMBER: 079200398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 having cleaners and deoerizers inaceable to clients and shed in backyard unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Administrator locked deoterized and cleaners in locked cabinet in gargage immediately and locked shed. Deficiency cleared during visit.
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:Bennett Fong
LICENSING EVALUATOR NAME:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 05:58 PM - It Cannot Be Edited


Created By: David Doidge On 11/26/2024 at 05:31 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: DONCASTER HOUSE
FACILITY NUMBER: 079200398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
The licensee shall meet the following food supply and storage requirements:

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.


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 not having staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days maintained on the premises which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Adminstrator agreed to purchase food and submit picture of food and recipt to CCLD by POC date.
Type B
Section Cited
CCR
80087(c)
All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard 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 in having futon cushion, sheetrock, broken chair and bench in backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2024
Plan of Correction
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Administrator agreed to have items removed and provide picture to CCL by POC 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:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 05:58 PM - It Cannot Be Edited


Created By: David Doidge On 11/26/2024 at 05:41 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: DONCASTER HOUSE
FACILITY NUMBER: 079200398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
All window screens shall be in good repair and be free of insects, dirt and other debris.

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 as patio door screen was in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2024
Plan of Correction
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Administrator agrees to have screendoor repaired and provide picture of repair to CCL by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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