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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200813
Report Date: 07/16/2021
Date Signed: 07/16/2021 11:23:04 AM

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 1FACILITY NUMBER:
079200813
ADMINISTRATOR:BERNARDINO, JANE PABUSTANFACILITY TYPE:
740
ADDRESS:3109 CONCORD BLVDTELEPHONE:
(925) 470-7160
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 4DATE:
07/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Jane BernadinoTIME COMPLETED:
11:30 AM
NARRATIVE
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On 07/16/2021 at approximately 9:44am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a case management visit regarding a self-reported incident that occurred on 06/06/2021. LPA met with Administrator, Jane Bernadino and explained the purpose of the visit.

During the visit LPA spoke and reviewed incident with Administrator. Administrator stated that facility was responsible for notifying hospice agency when Resident R1's medications need a refill. On 06/04/2021 the facility contacted R1's hospice agency notifying agency that R1 would need a refill of seizure medication by 06/05/2021 in the afternoon. On 06/04/2021 R1 was no longer receiving hospice services and medications had been sent to R1's medical provider. The facility then contacted R1's medical provider on 06/04/2021, but the medical provider did not have the medication order. On 06/05/2021 R1 took R1's last pill of medication in the morning and the facility did not receive the medication until 06/06/2021. On 06/06/2021 R1 had a seizure.

The following deficiency was cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2021
Section Cited

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in
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obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview and record review Licensee did not comply with the section cited above. Facility reached out to Resident R1's medical provider when R1 had one pill left which poses an immediate risk to the health and safety of residents 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021
LIC809 (FAS) - (06/04)
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