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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200914
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:34:38 PM

Document Has Been Signed on 11/30/2023 04:34 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:HARBOUR PLACE LLCFACILITY NUMBER:
079200914
ADMINISTRATOR:LIMJOCO, ALFREDOFACILITY TYPE:
735
ADDRESS:3000 HARBOUR DRIVETELEPHONE:
(415) 239-8145
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 1DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Javier Arriaga, CaregiverTIME COMPLETED:
04:30 PM
NARRATIVE
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On 11/30/2023 at 12:30pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Javier Arriaga, Caregiver, and explained the purpose of the visit. The administrator, Alfredo Limjoco, arrived at 12:45pm. The administrator currently holds a certificate (#6048327735) that expires on 05/20/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) total bedrooms and two (2 ) bathrooms. One (1) bedroom being used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 144.2 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster and soap observed at all hand washing stations. The supply of extra hygiene was available for residents.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 9/9/2023. Fire drill last conducted 11/6/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: HARBOUR PLACE LLC
FACILITY NUMBER: 079200914
VISIT DATE: 11/30/2023
NARRATIVE
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Continued from LIC809.

LPA reviewed four (4) staff files. Administrator file was not available for review. LPA reviewed client file that was missing the appraisal needs and services plan. P & I was not available for review.

The following forms to be updated and submitted to CCLD by 12/8/2023:
  • LIC610D Emergency disaster plan
  • Surety Bond
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources


LPA observed the following deficiencies:
  • At 12:35pm, LPA observed during record review that S2 was not associated to the facility.
  • At 1:30pm, LPA observed during record review S1 file was not available to review at facility.
  • At 1:45pm, LPA observed patio screen door with screen in disrepair.
  • At 1:50pm, LPA observed hot water measuring at 144.2.
  • At 2:30pm, LPA observed exit door in room #2 locked and staff was not able to locate key.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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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: HARBOUR PLACE LLC
FACILITY NUMBER: 079200914
VISIT DATE: 11/30/2023
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Continued from LIC809C.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $500.00 civil penalty will be assessed on today's date for fire clearance.*

Exit interview conducted. A copy of the LIC421IM, this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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Page: 3 of 7
Document Has Been Signed on 11/30/2023 04:34 PM - It Cannot Be Edited


Created By: Laura Hall On 11/30/2023 at 03:54 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: HARBOUR PLACE LLC
FACILITY NUMBER: 079200914

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 in having hot water under 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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3
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Administrator agreed to turn hot water temperature down to measure between 105 - 120 and submit picture with water running to show measurement to CCLD by POC date.
Type A
Section Cited
CCR
80019(e)(3)
80019 Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

(3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

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 in having S2 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Administrator associated S2 to facility during visit. Deficiency cleared during visit.
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/30/2023 04:34 PM - It Cannot Be Edited


Created By: Laura Hall On 11/30/2023 at 03:54 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: HARBOUR PLACE LLC
FACILITY NUMBER: 079200914

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 in having the patio screen door repaired. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator agreed to replace screen and place a handle on patio screen door and submit a photo to CCLD by POC date.
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


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Page: 5 of 7
Document Has Been Signed on 11/30/2023 04:34 PM - It Cannot Be Edited


Created By: Laura Hall On 11/30/2023 at 04:03 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: HARBOUR PLACE LLC
FACILITY NUMBER: 079200914

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(7)
80072 Personal Rights

(7) Not to be locked in any room, building, or facility premises by day or night.

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 in having exit door locked and not able to locate key which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Administrator agreed to remove locks and submit photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/30/2023 04:34 PM - It Cannot Be Edited


Created By: Laura Hall On 11/30/2023 at 04:08 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: HARBOUR PLACE LLC
FACILITY NUMBER: 079200914

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:


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 in having S1's file available for review and missing documents from other staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator agreed to complete all staff files and submit self certification to CCLD by POC date that the files are completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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3
4
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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