079200529-8-12-2022-15-AS-CFOR-CH8QKY-20220812121508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200529
Report Date: 08/12/2022
Date Signed: 08/12/2022 12:15:21 PM

Document Has Been Signed on 08/12/2022 12:15 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:	PENNY'S GUEST HOME		FACILITY NUMBER:	079200529
ADMINISTRATOR:	ANGCLA, EPIFANIA		FACILITY TYPE:	740
ADDRESS:	1768 CANTRELL CT		TELEPHONE:	(925) 286-0424
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 6	DATE:	08/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mariesol Gestiada, Caregiver		TIME COMPLETED:	12:30 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 08/12/2022 at 9:35 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Mariesol Gestiada and explained the purpose of the visit. Administrator Epifania Angcla arrived at approximately 9:54am. Upon entry, LPA temperature was not checked. LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters. During record review, LPA observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation. The following deficiencies were observed during the visit: -At 9:32am, LPA observed medication on the dining room table. -At 9:33am, LPA observed the key hanging from the medication cabinet. -At 9:52am, LPA observed laundry detergent, bleach, clorox wipes, bono floor cleaner, disinfectant, pine sol, turf builder and bug be gone in the unlocked garage. -At 9:58am, LPA observed 2 saws, bolt cutters, paint, shovel, 2 propane tanks, ladder, and weed eater in an unlocked shed. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

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: PENNY'S GUEST HOME	FACILITY NUMBER: 079200529
	VISIT DATE: 08/12/2022

NARRATIVE

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Continue from LIC809

-At 10:05am, LPA observed a washing machine, 2 vacuum cleaners, window with glass, bedframe, boxes, and picture frame with broken glass.
-At 10:07am LPA observed broken fence on both sides of the property.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/12/2022 12:15 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: PENNY'S GUEST HOME	FACILITY NUMBER: 079200529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 by having medication on the dining table and the key to the medication hanging in the cabinet, which poses an immediate health and safety to persons in care.
	POC Due Date: 08/13/2022
	Plan of Correction
1 2 3 4	Administrator met with caregivers about the importance of not having medications accessible to residents in care. Caregiver locked the medication in the locked cabinet and put the key in her pocket. Deficiency cleared during visit.

Type A

Section Cited

CCR

87309(a)(1)

87309(a)(1) (1) 87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Storage areas for poisons... shall be locked.This requirement was not met as evidence by 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 by having cleaning supplies such as laundry detergent, turf builder, bleach, clorox wipes, bono floor cleaner, disinfectant, and pine sol in an unlocked garage accessible to residents in care which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/13/2022
	Plan of Correction
1 2 3 4	Administrator agreed to turn the garage door lock around to make the garage inaccessible to residents in care and email photos to CCLD no later then the 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	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/12/2022 12:15 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: PENNY'S GUEST HOME	FACILITY NUMBER: 079200529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation 87303(a) (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 by having an unlocked shed with 2 saws, weed eater, bolt cutters, paint, shovel in an unlocked shed located in the backyard, a broken fence on the right and left side of the backyard. Washing machine, 2 vacuum cleaners, window, bedframe, boxes, broken frame with glass in the walkway. which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/02/2022
	Plan of Correction
1 2 3 4	Administrator agreed to lock shed and have washing machine, 2 vacuum cleaners, window, bedframe, boxes, broken frame with glass removed from the facility and to have the fence repaired

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC809 (FAS) - (06/04)

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