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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200574
Report Date: 02/01/2023
Date Signed: 02/01/2023 11:11:47 AM


Document Has Been Signed on 02/01/2023 11:11 AM - 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:
02/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jean Sanjuan, CaregiverTIME COMPLETED:
11:15 AM
NARRATIVE
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On 02/1/2023 at 10:00 am, Licensing Program Analysts (LPAs) C. Fowler and P. Watson arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Emcy Madriaga Levin and explained the purpose of the visit.

Upon entry, LPA temperatures were checked by staff. LPAs toured facility including but not limited to bedrooms, bathroom, 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, LPAs observed visitors log and temperature logs for residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPE and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 10:17 am, LPAs observed 2 ladders, shovels, paint cans, ply wood, wood planks located in backyard
-At 10:24 am LPAs observed cabinet in kitchen unlocked with key hanging from lock.

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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 02/01/2023 11:11 AM - 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: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 having the cabinet with knives unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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Administrator agreed to conduct an in-service training with staff and provide
CCLD with a list of signatures of the attendees.
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: 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: 2 of 3


Document Has Been Signed on 02/01/2023 11:11 AM - 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: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
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
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Based on LPAs observation licensee did not comply with the section cited above by having 2 ladders, shovel, paint cans, ply wood, wood planks, which poses a potential health and safety risk to residents
POC Due Date: 02/22/2023
Plan of Correction
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Licensee agreed remove all items from the backyard and provide photos to CCLD 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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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 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