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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200627
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:01:37 PM

Document Has Been Signed on 12/01/2022 03:01 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:DINAMI HOME INCFACILITY NUMBER:
079200627
ADMINISTRATOR:RIDEOUT, TWYLAFACILITY TYPE:
735
ADDRESS:26 MURILLO COURTTELEPHONE:
(510) 689-9552
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 4DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Twyla Rideout, Administrator TIME COMPLETED:
03:20 PM
NARRATIVE
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On 12/1/2022 at 1:00PM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and met with Administrator Twyla Rideout. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 70 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.

LPA observed the following:
· Administrator cannot provide proof of training on infection prevention, symptoms, transmission and PPE use.


…Continued to LIC809C…
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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: DINAMI HOME INC
FACILITY NUMBER: 079200627
VISIT DATE: 12/01/2022
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LPA provided technical assistance on the following topics:

· Signing up to receive Provider Information Notices (PINs)
· Administrator needs to submit infection control from no later than 12/5/2022
· Facility needs additional PPE supplies. LPA discussed that facility needs 30 days PPE supplies on hand.
· Facility needs to conduct routine symptom screening (+/- temperature and symptom check) at entry for all staff, residents, and visitors.
· Facility needs to document daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents.
· LPA provided resources for N95 Fit testing. LPA discussed the importance of proper N95 fitting.
· LPA reminded Administrator that all sinks need paper towel, trash bin with lid and hand washing poster.
· LPA discussed with Administrator that PPEs needs to be stored in a location that is readily accessible to staff.
· LPA discussed with Administrator that signs need to be posted at facility entrance with updates to visitor policy to notify of policies and procedures
· Submit updated LIC500 and updated client’s rooster.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Twyla Rideout, Administrator.



Exit interview conducted and appeal rights copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/01/2022 03:01 PM - It Cannot Be Edited


Created By: Leslie Ibo On 12/01/2022 at 02:34 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: DINAMI HOME INC
FACILITY NUMBER: 079200627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which Administrator cannot provide proof of covid19 training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Administrator agreed to train all staff on Covid19 infection prevention, symptoms, transmission and PPE use.
Proof of training needs to be submitted on or before 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022


LIC809 (FAS) - (06/04)
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