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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200783
Report Date: 06/09/2021
Date Signed: 06/11/2021 04:19:35 PM

Document Has Been Signed on 06/11/2021 04:19 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:B. RUIZ CAREHOME 2FACILITY NUMBER:
079200783
ADMINISTRATOR:JAMIE RUIZFACILITY TYPE:
740
ADDRESS:30 MERGANSER CTTELEPHONE:
(925) 698-1207
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
06/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jaime Ruiz & Joyce PeleaTIME COMPLETED:
01:15 PM
NARRATIVE
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*Amended* While conducting annual required inspection Licensing Program Analyst(LPA) Leslie Ibo conducted a Case Management with Administrator Jaime Ruiz and house manager Joyce Pelea, in relation to the incident report submitted on 6/8/2021, R1 had un-witnessed fall in the bathroom on 6/4/2021.

During the interview S1 assisted R1 to the bathroom and stayed outside the bathroom to provide privacy, while other staff ( S2 ) was at the kitchen area. Based on R1’s assessment report, R1 needed toilet assistance and based on physician’s report R1 is non-ambulatory, confused with Dementia diagnosis. LPA interviewed Administrator, based on interview conducted R1 is fall risk and needed staff to assist R1 inside the toilet.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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 06/11/2021 04:09 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/10/2021 03:53 PM


Created By: Leslie Ibo On 06/09/2021 at 12:40 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: B. RUIZ CAREHOME 2
FACILITY NUMBER: 079200783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2021
Section Cited
CCR
87465(a)(1)

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87565(a)(1) Incidental Medical and Dental Care. (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Administrator states staff will be retrained on procedures for assisting residents based on each needs and services plan, specifically fall risk residents who needed assistance while using the toilet/bathroom.
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This requirement is not met as evidenced by licensee's failure to ensure the resident's needs were met & injuries sustained from falls. Which poses an immediate risk to the health and safety of resident's in care. R1 had laceration on forehead and bruises.
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Proof of in-service training will be sent to LPA via email by POC date.

*Immediate $500.00 civil penalty was assessed.
Facility Administrator terminated both S1 & S2 on 6/10/2021. Administrator Jaime trained all staffs regarding fall prevention, a copy of training was given to LPA L.Ibo.

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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: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021


LIC809 (FAS) - (06/04)
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