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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200815
Report Date: 11/29/2021
Date Signed: 11/29/2021 03:09:16 PM

Document Has Been Signed on 11/29/2021 03:09 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:WEAVER LANE GUEST HOMEFACILITY NUMBER:
079200815
ADMINISTRATOR:GARDNER, JOSEFINAFACILITY TYPE:
740
ADDRESS:842 WEAVER LNTELEPHONE:
(925) 676-5376
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 5DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Licensee, Josefina Gardner TIME COMPLETED:
03:18 PM
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On 11/29/2021 at 2:03 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with licensee Josefina Gardner and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week nonperishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan.

The following deficiency was observed during the visit:
At 2:25 PM LPA observed a gate in disrepair, and was unable to stay closed

Appeal rights were given and exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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 11/29/2021 03:09 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 11/29/2021 at 02:51 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: WEAVER LANE GUEST HOME
FACILITY NUMBER: 079200815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, licensee did not comply with the section cited above by having an inoperable gate which poses a potential health and safety risk to the residents in care.
POC Due Date: 12/06/2021
Plan of Correction
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Administrator will submit receipt or photo to show the gate was repaired by POC date. If administrator is unable to repair the gate by POC date, a plan will be submitted to CCLD on how long it would take to repair the gate to operable condition.
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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021


LIC809 (FAS) - (06/04)
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