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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200578
Report Date: 08/24/2023
Date Signed: 08/24/2023 02:16:20 PM

Document Has Been Signed on 08/24/2023 02:16 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CORDIAL CARE HOMEFACILITY NUMBER:
079200578
ADMINISTRATOR:OKEIGWE, OGEDIFACILITY TYPE:
740
ADDRESS:2957 HANNAN DRIVETELEPHONE:
(925) 947-5812
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 4DATE:
08/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marilin "Lin" Alegria, CaregiverTIME COMPLETED:
02:25 PM
NARRATIVE
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On 08/24/2023 at 11:00 AM, Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct an continued 1-Year Annual Required inspection from previous visit on 07/26/2023. LPAs met with Caregiver, Marilin "Lin" Alegria and explained the purpose of the visit. LPA spoke with Administrator, Ogedi Okeigwe, via telephone.

LPAs reviewed 4 resident files from previous visit on 07/26/23. LPAs reviewed 1 resident file on today's visit.
LPAs reviewed 6 staff files and 5 of 6 staff had CPR/AED/First Aid training and associated to the facility.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

LPAs observed during visit on 7/26/2023, that Licensee/Administrator was out of the country and had been for approximately a month and did not notified CCLD of their absence. There was no substitute Administrator notified.

LPAs observed during record review that S4, S5 and S6 was missing health screening and TB tests.

LPAs observed during record review and interview that R4 expired on 8/17/2023. Facility did not submit a death report to CCLD.

LIC 809C Continued
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CORDIAL CARE HOME
FACILITY NUMBER: 079200578
VISIT DATE: 08/24/2023
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LIC 809 Continued...

LPAs observed R1 was admitted into hospice services on 7/13/2023. Facility did not notify CCLD of hospice services.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 08/31/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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Document Has Been Signed on 08/24/2023 02:16 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 08/24/2023 at 01:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CORDIAL CARE HOME
FACILITY NUMBER: 079200578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)
87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in by notifying Licensing of hospitalizations, and death which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee/Administrator agreed to read section 87211 and submit self- certification that the regulation has been reviewed and he will abide by the regulation going forward. Self-certification will be submitted to CCLD by POC Due Date.
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements – General
(f) All personnel, including the licensee and administrator, shall be in good health...health screening...chest x-ray

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in by not having health screening and TB tests for S4, S5 and S6 which poses a potential health and safety risk to residents in care.
POC Due Date: 08/31/2023
Plan of Correction
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Licensee/Administrator will complete a health screening and TB test for S4, S5 and S6 and will submit copies of completed results to CCLD by POC Due 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
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


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Document Has Been Signed on 08/24/2023 02:16 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 08/24/2023 at 01:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CORDIAL CARE HOME
FACILITY NUMBER: 079200578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(d)(2)
87632 Hospice Care Waiver
(d) If the Department grants a hospice care waiver it shall stipulate terms...(2)The licensee shall notify the Department in writing within five working days of the initiation of hospice care services...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in by not notifying Licensing of residents that have started hospice services which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee/Administrator shall review section 87632 and self-certify that they have read the regulation. Self-certification will be submitted to CCLD by POC Due 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 Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


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