079200924-9-23-2021-15-AS-DPAO-C75QQW-20210923122300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200924
Report Date: 09/23/2021
Date Signed: 09/23/2021 12:23:12 PM

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, LLC		FACILITY NUMBER:	079200924
ADMINISTRATOR:	MALEKAMU, MARY		FACILITY TYPE:	740
ADDRESS:	1841 FLORENCE LN		TELEPHONE:	(925) 698-1736
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 3	DATE:	09/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Mary Malekamu, Administrator		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/25/21 at 11:15 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. Facility has a completed mitigation plan in place dated 03/01/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) and COVID-19 infection control practices with administrator. LPA inspected the facility inside and outside. LPA observed a screening station located near the front entrance with visitor's log, hand sanitizer, face masks, no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. A written emergency/disaster plan was observed last updated on 01/22/2020. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

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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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: 09/23/2021

NARRATIVE

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Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since March 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 75 degrees Fahrenheit. Medications were observed locked in the office cabinet. Toxic chemicals were observed locked in the laundry room and garage. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged and last inspected on 04/20/21. Smoke and Carbon monoxide detectors were operational.

Updated copies of the following documents were requested to be emailed to LPA on 09/24/21:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies were observed during the infection control annual inspection.
Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

LIC809 (FAS) - (06/04)

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