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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200513
Report Date: 06/09/2023
Date Signed: 06/09/2023 02:25:10 PM


Document Has Been Signed on 06/09/2023 02:25 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WELCOME HOME SENIOR RESIDENCE (CONCORD 2)FACILITY NUMBER:
079200513
ADMINISTRATOR:STEVEN CHOUFACILITY TYPE:
740
ADDRESS:807 WEAVER LANETELEPHONE:
(510) 685-8388
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 5DATE:
06/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Ivee RegaladoTIME COMPLETED:
02:30 PM
NARRATIVE
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On 06/09/2023 while at the facility for a different purpose, Licensing Program Analyst (LPA) conducted a case management. LPA spoke with house manager, Clara Delgado and explained the purpose of the visit. Clara designated Ivee Regalado to sign off on the report.

On January 30, 2023, the facility issued a 2-day notice of rate increase for R1 stating that there was drastic increase of R1’s needs since the initial assessment. The increase notice did not include detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges as required in the regulations.

Based on LPA’s interviews and record review, the last Appraisal/Needs and Services plan done for R1 occurred on 09/07/2022. In interviews both S1 and S2 stated that R1 has required more attention from the staff since she join the facility on 07/09/2022 indicating that there has not been a change of needs for R1.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

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

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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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Document Has Been Signed on 06/09/2023 02:25 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: WELCOME HOME SENIOR RESIDENCE (CONCORD 2)
FACILITY NUMBER: 079200513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
HSC
1569.657(a)

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For any rate increase due to a change ...The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.
This requirement was not met as evidence by:
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The facility agrees to submit a written statment stating that they have reviewed the regulation and LIC 625 form. The written statment will be sent to CCLD by POC date.
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Based on records review and interviews the facility did not give a detailed explanation of or record for new level of care or provide the additional services to be provided at the new level of care or provide
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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