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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200398
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:02:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/26/2023 12:02 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DONCASTER HOUSEFACILITY NUMBER:
079200398
ADMINISTRATOR:ROWELL FERRERFACILITY TYPE:
735
ADDRESS:1001 DONCASTER AVETELEPHONE:
(925) 779-1830
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 5DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maricon Uy, CaregiverTIME COMPLETED:
12:10 PM
NARRATIVE
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On 10/26/2023 at 10:00am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Maricon Uy, Caregiver, and explained the purpose of the visit. Administrator, Albert Espino, arrived at 10:20am. The administrator currently holds a certificate (#6061533735) that expires on 11/24/2023. The facility’s fire clearance was approved for six (6) non-ambulatory clients.

LPA 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. Two (2) bedrooms are occupied by staff. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degrees Fahrenheit. LPA 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 110.1 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. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 01/31/2023. Fire drill last conducted 10/17/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DONCASTER HOUSE
FACILITY NUMBER: 079200398
VISIT DATE: 10/26/2023
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Continued from LIC809.

Four (4) staff records were reviewed, and all staff have first aid certification. All five client records were reviewed, current, and completed. LPA reviewed P & I.

The following forms to be updated and submitted to CCLD by 11/2/2023:
  • LIC610D Emergency disaster plan.
  • Liability insurance.
  • Surety Bond
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources


LPA observed the following deficiencies:
  • At 11:10am, LPA observed kitchen cabinet underneath sink unlocked and contained, Ajax, Lysol disinfectant, Raid, and knives.
  • At 11:20am, LPA observed a non operating refrigerator, freezer, and oven in the back yard.

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: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/26/2023 12:02 PM - It Cannot Be Edited


Created By: Laura Hall On 10/26/2023 at 11:41 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: DONCASTER HOUSE
FACILITY NUMBER: 079200398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2023
Section Cited
CCR
80087(g)

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80087 Buildings 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 was not met as evidence by:
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The Caregiver immediately locked the cabinet with a padlock
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Based on observation the Licensee did not comply with the section cited above in have disinfectants and knives inaccessible to clients which poses a potential health and safety risk to persons in care.
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Type B
11/06/2023
Section Cited
CCR80087(c)

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80087 Buildings and Grounds (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 was not met as evidence by:
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The Administrator agreed to have the oven, freezer, and refrigerator removed and submit copy of picture to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having passageway cleared which poses a potential health and safety risk to persons in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
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