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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200924
Report Date: 09/23/2024
Date Signed: 09/23/2024 01:32:15 PM


Document Has Been Signed on 09/23/2024 01:32 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: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:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mary 'Rose' Malekamu/AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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On 09/23/24 at 11:00 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Mary 'Rose' Malekamu/Administrator and explained the purpose of the visit.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 04/16/2024.

At 12:02 pm LPA reviewed 4 residents records. At 12:45 pm, LPA reviewed 2 staff records and 2 of 2 were fingerprint cleared and associated to the facility.

Continued on LIC809C...
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
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 5


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: 09/23/2024
NARRATIVE
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...Continued from LIC 809
The following deficiency was observed during the visit:
  • Chemicals in Laundry room and bathroom left unlocked
  • Staff records are not complete
  • R4 does not have admissions agreement in file
  • Residents do not have Safeguard Property and Valuables form in files
  • R1 and R2 need updated medical assessments
  • No sign for oxygen tank

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/23/2024 01:32 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 chemicals unlocked in the laundry room and bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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The facility agrees to lock away chemicals and to read and review the regulation and submit a letter of self certification to CCLD by POC date.
Type B
Section Cited
CCR
87412(a)
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 record review, the licensee did not comply with the section cited above by having all staff records mixed together in one binder which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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The facility agrees to separate each staff record. Proof of correction will be sent to CCLD by POC date.
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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/23/2024 01:32 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

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 R4 did not have an admissions agreement in his file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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The facility agrees to get a signed admissions agreement for R4s file. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

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 by not having a record of residents Personal Property, and Valuables which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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The facility agrees to get a signed record of each residents Personal Property, and Valuables . Proof of correction will be sent to CCLD by POC date.
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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/23/2024 01:32 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 not having signs for the oxygen tank that is stored in R1's room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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The facility agrees to post sign outside R1's room and at the front door stating "No Smoking-Oxygen in Use” Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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 by not having an updated medical assessment for R1 and R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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The facility agrees to get updated medical assessments for residents. Proof of correction will be sent to CCLD by POC date.
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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5