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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200783
Report Date: 04/24/2024
Date Signed: 04/24/2024 04:27:23 PM

Document Has Been Signed on 04/24/2024 04:27 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:B. RUIZ CAREHOME 2FACILITY NUMBER:
079200783
ADMINISTRATOR/
DIRECTOR:		JAMIE RUIZFACILITY TYPE:
740
ADDRESS:30 MERGANSER CTTELEPHONE:
(925) 698-1207
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Marilou Intog House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:36 PM
NARRATIVE
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On 04/24/2024 at 12:40PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and C. Fowler conducted an unannounced 1-Year Required inspection. LPAs met with House manager Marilou Intog, and explained the purpose of the visit. Marilou called the Administrator who arrived to the facility at 3:04PM. Administrator currently holds a certificate (#7035384740) that expires on 10/04/2025. Facility has census of 6. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPAs toured the facility with House Manger including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 113.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 007/19/2023. Emergency Disaster Plan was last posted on 11/03/2023. First aid kit was observed to be complete. Fire drill was last conducted on 03/16/2022.

Four (4) staff records were reviewed. During record review . LPA reviewed three (3) resident records, and they were current and complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: B. RUIZ CAREHOME 2
FACILITY NUMBER: 079200783
VISIT DATE: 04/24/2024
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Continued from LIC809.

LPAs requested the following documents to be submitted to CCLD by 05/01/2024.

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

LPAs observed the following deficiencies:
  • At 12:55pm LPAs observed medications in an unlocked cabinet in kitchen
  • At 1:00pm LPAs observed disinfectants in unlocked cabinet under kitchen sink
  • At 1:15pm LPAs observed bleach, fabuloso, comet and Lysol spray under the unlocked sink cabinet in the common bathroom
  • At 1:18pm LPAs observed a room with a bed and clothing in closet in common bathroom
  • At 1:25pm LPAs observed a lawn mower, area rug, and exercise equipment near emergency exit gate



Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2024 04:27 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 04/24/2024 at 03:54 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: B. RUIZ CAREHOME 2
FACILITY NUMBER: 079200783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia (RCFE)
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in having disinfectants locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Caregiver immediately locked cabinets during visit. Deficiency cleared.
Type A
Section Cited
CCR
87465(2)
87465 Incidental Medical and Dental Care (RCFE)
2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in not having centrally stored medications locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Administrator removed medicine from cabinet with broken lock during visit. Deficiency cleared.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/24/2024 04:27 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 04/24/2024 at 04:04 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: B. RUIZ CAREHOME 2
FACILITY NUMBER: 079200783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
87307 Personal Accommodations and Services (RCFE)
(a) Individual privacy shall be provided in all toilet, bath and shower areas.

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 in having closet in common bathroom use as staff's room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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Administrator agreed to clear staff room and convert it back to a closet and send photos via email to CCLD by 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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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