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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200916
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:14:47 PM

Document Has Been Signed on 05/17/2022 02:14 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:OUR HOMEFACILITY NUMBER:
079200916
ADMINISTRATOR:BANSIL, REYNANTEFACILITY TYPE:
735
ADDRESS:9692 TAREYTON AVENUETELEPHONE:
(510) 220-6712
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 5DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Reynante Bansil, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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On 5/17/2022 starting at 12:10 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPAs were greeted by Eumelia Mendoza. Administrator, Reynante Bansil later arrived at 12:38 PM.

During the Infection Control Inspection, LPAs toured facility with Care Staff 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 non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy and thermometer were observed. Social distancing poster were observed. Common touched surfaces are disinfected at least once daily. Facility staff were observed to be wearing proper PPE.

At 1:50 PM, LPAs reviewed 5 staff records and 3 of 5 have a health screening and TB test on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff.



REPORT CONTINUES ON 809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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: OUR HOME
FACILITY NUMBER: 079200916
VISIT DATE: 05/17/2022
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/20/2020:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • Current Administrator’s Certificate

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2022 02:14 PM - It Cannot Be Edited


Created By: Lizette Francisco On 05/17/2022 at 02:01 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: OUR HOME
FACILITY NUMBER: 079200916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(g)(1)
80065(g)(1) Personnel Requirements
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks. (1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. 2 of 5 staff does not have health screening and TB results on file which poses a potential health and safety risk to residents in care.
POC Due Date: 05/27/2022
Plan of Correction
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By POC date, Administrator agrees to submit a copy of health screening with TB test results to CCLD.
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:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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