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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200627
Report Date: 10/12/2023
Date Signed: 10/12/2023 05:51:11 PM

Document Has Been Signed on 10/12/2023 05:51 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: 2DATE:
10/12/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Twyla Rideout/AdministratorTIME COMPLETED:
05:45 PM
NARRATIVE
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On this day, October 12, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20231009165621). LPA was granted entry by staff, Darren Jones. LPA spoke over the phone with Twyla Rideout, administrator, and informed the reason for visit. Administrator arrived after about 30 minutes.

The two residents were present when LPA arrived and went out for an outing with Darren Jones when administrator arrived.

LPA toured the facility inside out with the administrator. LPA inspected the living and family rooms, dining area, kitchen, residents and staff rooms, side and backyard. Hot water in the common bathroom was tested and measured at 119.7 degrees Fahrenheit. Central storage for medications was observed locked.

LPA learned from the administrator that there were residents who tested positive of COVID-19 on February 2023, and a resident passed away in April 2023. Administrator stated she completed the SIRs for the COVID-19 and submitted to Regional Center of East Bay but not to Community Care Licensing (CCL). Death report was also not submitted to CCL.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates along with the LIC9098 Proof of Correction, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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Document Has Been Signed on 10/12/2023 05:51 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/12/2023 at 04:29 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: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2023
Section Cited
CCR
80061(b)(1)(A)

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80061 Reporting Requirements
(b) ..a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report....shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Administrator to read the Regulations.
In addition, administrator to submit a copy pf LIC624A Death Report by 10/19/23.
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 (1)(A)Death of any client from any cause.
This requirement is not met as evidenced by:
-Based on interview and records review, the licensee did not comply with the section above for not sending death report which posed potential personal rights risk to person in care.
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Type B
10/19/2023
Section Cited
CCR80061(a)

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80061 Reporting Requirements
(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.

-This requirement is not met as evidenced by:
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Administrator to submit copies of incident reports by 10/19/23.
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-Based on interview and records review, the licensee did not comply with the section above for not sending incident reports when residents tested positive of COVID-19 which posed potential heatth and personal rights risks to persons in care.
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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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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