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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200850
Report Date: 08/17/2021
Date Signed: 08/17/2021 11:22:25 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 2FACILITY NUMBER:
079200850
ADMINISTRATOR:BERNARDINO, JANE PFACILITY TYPE:
740
ADDRESS:3105 CONCORD BLVDTELEPHONE:
(925) 470-7160
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 3DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Alberto Bernardino, AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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On 8/17/2021 at 8:35AM, Licensing Program Analysts (LPAs) G. Luk and J. Clancy-Czuleger arrived unannounced to conduct an Infection Control Inspection. LPAs met with staff, Maricel David and explained the purpose of the visit. Administrator, Alberto Bernardino arrived an hour later.

Upon entry, LPA's temperatures were checked and asked to fill out COVID-19 questionnaire. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, living room, and outdoor areas. LPAs observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log and temperature logs for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed food and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 9:00AM, LPAs observed unlocked scissors in the kitchen and unlocked cleaning supplies. Staff locked up scissors and cleaning supplies during inspection.
-At 9:10AM, LPAs observed the medication cabinet was unlocked. Staff locked the medication cabinet during inspection.
-At 9:20AM, LPAs observed that resident had full bed rail and was not on hospice care. Staff removed the full bed rails during inspection.
-At 9:45AM, LPAs observed that staff was not associated to the facility. Administrator provided LIC9182 and a copy of ID to LPAs during inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6
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 2
FACILITY NUMBER: 079200850
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having unlocked cleaning supplies and scissors which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/18/2021
Plan of Correction
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Staff locked up the scissors and cleaning supplies during inspection.

Deficiency cleared during inspection.
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 by not associating staff to the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/18/2021
Plan of Correction
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Administrator provided LIC9182 and a copy of ID for staff during inspection.

Deficiency cleared during inspection.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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 2
FACILITY NUMBER: 079200850
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (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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3
4
Based on observation, the licensee did not comply with the section cited above by having unlocked medications which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/18/2021
Plan of Correction
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Staff locked the medication cabinet during inspection.

Deficiency cleared during inspection.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having a full bed rail for a resident who is not on hospice care which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/18/2021
Plan of Correction
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Staff removed the full bed rail during inspection.

Deficiency cleared during inspection.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6