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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200924
Report Date: 08/18/2020
Date Signed: 08/18/2020 11:27:53 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:A OHANA HOME FOR SENIORS, LLCFACILITY NUMBER:
079200924
ADMINISTRATOR:MALEKAMU, MARYFACILITY TYPE:
740
ADDRESS:1841 FLORENCE LNTELEPHONE:
(925) 698-1736
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 4DATE:
08/18/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Mary MalekamuTIME COMPLETED:
11:30 AM
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On 8/18/20 at 10:10 am LPA Rolanda Pitcher conducted an announced video tele-visit, meeting with Applicant, Mary Malekamu for the purpose of conducting a pre-licensing visit.
Due to the current Governor's order to shelter-in-place due the visit could not be conducted in person. A video tour of the physical plant entire interior and exterior was performed. This home is currently licensed as a Residential Care Facility for Elderly - 079200391.

Physical Plant - The home is clean and in good repair. LPA observed two spacious dining areas, kitchen and living room; screens are in good repair; appropriate lighting is available in each room; all indoor and outdoor passageways are free of obstruction. physical plant is consistent with the submitted floor plan. There is a private administrator office, and disinfectants, cleaning solutions, poisons and other items that could pose a danger were locked and inaccessible; fire alarms, smoke alarms, and carbon monoxide detectors are operational.

Medications - LPA observed a centralized medications were locked in the administrator office in accessible to residents.

Bedrooms - Resident bedrooms are of adequate size. LPA observed a bedroom furnished with a chair, night stand, dresser drawer, and sufficient lighting. Bathrooms - LPA observed the bathtubs, showers, and toilets have grab bars; baths and showers have non-skid mats; all bathtubs, showers, toilets and sinks are operational; night light.

Report continued on 809C
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda PitcherTELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020
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 2
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: A OHANA HOME FOR SENIORS, LLC
FACILITY NUMBER: 079200924
VISIT DATE: 08/18/2020
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Records - There is confidential storage for personnel and resident records.

Food Service - LPA observed the kitchen was clean and sanitary; kitchen is clean and cleaning supplies are kept separate from food supply; there is a 7 day supply of perishable and 2 days of perishable foods in stock for six people; there are sufficient amount of tableware, tables, dishes, and utensils; there are sufficient amount of equipment for the storage, preparation of food; all equipment and dishes are clean and in good repair.

Supplies - LPA observed a sufficient supply of hygiene items and linen, blankets and towels.

Administration - Emergency exit plans and telephone numbers facility theft and loss program, personal rights, resident council rights are posted. Activities - There are game and reading materials available; there is an outdoor covered patio area furnished with patio furniture. Miscellaneous - There is a full first aid kit; laundry supplies and equipment in good repair; there is a space for clean and soiled linen.

The Component III was waived. Mary Malekamu demonstrated sufficient knowledge to operate a Residential Care Facility for Elderly.


Exit interview was conducted with Mary Malekamu
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda PitcherTELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2