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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200565
Report Date: 02/01/2023
Date Signed: 02/01/2023 02:52:25 PM


Document Has Been Signed on 02/01/2023 02:52 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:COZY FAMILY CAREFACILITY NUMBER:
079200565
ADMINISTRATOR:JI, RUIFACILITY TYPE:
740
ADDRESS:2135 LUPINE ROADTELEPHONE:
(510) 327-4408
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 5DATE:
02/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Celia Garcia, CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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On 02/01/2023 at 12:40pm Licensing Program Analysts (LPAs) C. Fowler and P. Watson arrived unannounced to conduct infection control inspection LPA's met with administrator, Rui Ji and explained the purpose of the visit. Administrator arrived at approximately 1:20pm.

During the Infection Control Inspection, LPAs toured facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Visitors policy is posted on the front door. Facility staff were observed wearing masks. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

The following deficiencies were observed during the visit:
-At 1:11 pm, LPAs observed hedge trimmers, and over the counter fish oil vitamins located in unlocked garage
-At 1:13 pm LPAs observed walker, shower chair, screen door, shovel, toilet top, hoyer lift, bed frame located in the backyard

Continue on 9099C

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
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: COZY FAMILY CARE
FACILITY NUMBER: 079200565
VISIT DATE: 02/01/2023
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continue from 9099

The following forms are to be updated and submitted to CCLD by 2/8/2023:

-LIC500 Personnel Report

-LIC308 Designation of Administrative Responsibility

-LIC610E Emergency Disaster Plan

-An updated copy of Administrator certificate

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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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/01/2023 02:52 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: COZY FAMILY CARE
FACILITY NUMBER: 079200565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide ... Postural supports may be... (3) A written order from a physician indicating... postural support shall be maintained... require other additional ...This requirement was not met as evidence by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation licensee did not comply with the section cited above by not having a written order for bed rails for R1 and R6 from a physician which poses a potential health and safety risk to residents in care.
POC Due Date: 02/15/2023
Plan of Correction
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Licensee agreed to submit a written doctors order for bedrails for R1 and R6 to CCLD no later than the POC date
Type B
Section Cited
CCR
87303(a)
87303(a) Maintenance and Operation

(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 was not met as evidence by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation licensee did not comply with the section cited above by having walker, shovel, shower chair, screen door, shovel, toilet top, Hoyer lift, bed frame, fish oil, and hedge trimmers and other items located in the backyard which poses a potential health and safety risk to residents
POC Due Date: 02/15/2023
Plan of Correction
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Licensee agreed remove all items walker, shovel, shower chair, screen door, shovel, toilet top, Hoyer lift, bed frame, fish oil, and hedge trimmers from the side yard and provide photos to CCLD no later than 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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3