079200813-6-15-2021-15-AS-DPAO-C3ZV25-20210615160234

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200813
Report Date: 06/15/2021
Date Signed: 06/15/2021 04:02:46 PM

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:	GABRIEL'S HOUSE 1		FACILITY NUMBER:	079200813
ADMINISTRATOR:	BERNARDINO, JANE PABUSTAN		FACILITY TYPE:	740
ADDRESS:	3109 CONCORD BLVD		TELEPHONE:	(925) 470-7160
CITY:	CONCORD	STATE: CA	ZIP CODE:	94519
CAPACITY:	6	CENSUS: 4	DATE:	06/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jane Bernardino, Administrator		TIME COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/15/21 at 2PM, Licensing Program Analyst (LPA) conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 2 staff wearing face masks during visit. LPA observed one central entry point designated for universal entry screening at the main entrance. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Per staff, the designated infection control leader is the administrator. LPA observed COVID-19 signages in common areas. Facility has a completed mitigation plan in place dated 01/06/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with staff as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed locked medication cabinets and locked toxic chemical cabinets located inside the laundry area. Adequate PPE supplies were observed in a separate storage shed located next to the laundry room. All staff and residents have been fully vaccinated since March 2021. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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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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: GABRIEL'S HOUSE 1	FACILITY NUMBER: 079200813
	VISIT DATE: 06/15/2021

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There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 72 degrees Fahrenheit. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational. A written Emergency/Disaster plan dated 10/11/20 was observed posted in the laundry room. Sharp objects were locked in the kitchen cabinet.

Updated copies of the following documents were requested for facility file and are to be emailed to LPA by 06/16/21:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC809 (FAS) - (06/04)

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