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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200778
Report Date: 11/07/2024
Date Signed: 11/07/2024 06:19:54 PM

Document Has Been Signed on 11/07/2024 06:19 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:SOPHIA'S HOMEFACILITY NUMBER:
079200778
ADMINISTRATOR/
DIRECTOR:		HAYAG, LORNAFACILITY TYPE:
735
ADDRESS:5243 CONCORD BLVDTELEPHONE:
(925) 683-1818
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Lorna Hayag, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On 11/7/2024 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Lorna Hayag and explained the purpose of the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 4/22/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 110.4 degrees F in the hallway bathroom. There were adequate lights in each room. First Aid kit is complete. LPA reviewed 6 clients and 3 staff files starting at 1:00PM. LPA reviewed a sample of client's medications. LPA interviewed 2 clients and 2 staff during inspection.

At 12:45PM, LPA observed unlocked vitamins in staff's room and unlocked gardening tools and insect killer granules in the backyard. Staff locked up the items during inspection.
At 12:50PM, LPA observed large amounts of vehicle tires, water heater, soil, toys, boxes of items were stored outside the storage shed and/or in the backyard.
At 1:30PM, LPA observed C2, C3, C5, and C6 does not have current IPP (Individual Program Plan) or ANS (Appraisal Needs and Service Plan) on file.
At 1:40PM, LPA observed C6 does not have TB test on file.
At 1:50PM, LPA observed S2 and S3 does not have TB test on file.
At 2:30PM, LPA observed facility did not conduct disaster drills every three months.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 6
Document Has Been Signed on 11/07/2024 06:19 PM - It Cannot Be Edited


Created By: Grace Luk On 11/07/2024 at 05:18 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: SOPHIA'S HOME
FACILITY NUMBER: 079200778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 unlocked vitamins, gardening tools, and insect killer granules which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Staff locked up the items during inspection.

Deficiency cleared.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/07/2024 06:19 PM - It Cannot Be Edited


Created By: Grace Luk On 11/07/2024 at 05:18 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: SOPHIA'S HOME
FACILITY NUMBER: 079200778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

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 by not having TB test for two staff which poses a potential health and safety risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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Administrator has agreed to obtain TB test results for S2 and S3 and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

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 by not having TB test for a client which poses a potential health and safety risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Administrator has agreed to obtain TB test for C6 and submit a copy to CCLD by POC 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/07/2024 06:19 PM - It Cannot Be Edited


Created By: Grace Luk On 11/07/2024 at 05:18 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: SOPHIA'S HOME
FACILITY NUMBER: 079200778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 by not conducting emergency/disaster drills quarterly which poses a potential health and safety risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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Administrator has agreed to conduct a disaster drill and submit document to CCLD by POC date.
Type B
Section Cited
CCR
80068.2(b)(1)
(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:
(1) The needs appraisal or IPP is not more than one year old.
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 by not having current IPP/ANS for clients which poses a potential health and safety risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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Administrator has agreed to obtain current IPP or ANS for C2, C3, C5, and C6. Administrator will submit copies to CCLD by POC 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/07/2024 06:19 PM - It Cannot Be Edited


Created By: Grace Luk On 11/07/2024 at 05:58 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: SOPHIA'S HOME
FACILITY NUMBER: 079200778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 tires, water heater, soil, boxes, and other items stored open in the backyard which poses a potential health and safety risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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Administrator has agreed to come up with a plan to store these items in an enclosed area and submit a copy of the plan to CCLD by 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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