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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200574
Report Date: 06/22/2022
Date Signed: 06/22/2022 01:53:13 PM


Document Has Been Signed on 06/22/2022 01:53 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:ABSOLUTE CARE FOR LIFEFACILITY NUMBER:
079200574
ADMINISTRATOR:LEVIN, EMCY MADRIAGAFACILITY TYPE:
740
ADDRESS:1700 MARLESTA ROADTELEPHONE:
(510) 478-8926
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 5DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Emcy Madriaga Levin, AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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On 06/22/2022 at 12:30 pm, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Emcy Madriaga Levin and explained the purpose of the visit.

Upon entry, LPA temperatures were checked by staff. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitors log and temperature logs for residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 12:30pm, LPA observed an added room located in the garage.

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: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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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Document Has Been Signed on 06/22/2022 01:53 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: ABSOLUTE CARE FOR LIFE
FACILITY NUMBER: 079200574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Added room without permit 87305(a)

Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

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 by adding an additional room located in the garage which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Administrator will submit approved permit from the local county department along with a new facility sketch to CCL no later than the 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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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