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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200924
Report Date: 12/23/2021
Date Signed: 12/23/2021 04:51:10 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, LLCFACILITY NUMBER:
079200924
ADMINISTRATOR:MALEKAMU, MARYFACILITY TYPE:
740
ADDRESS:1841 FLORENCE LNTELEPHONE:
(925) 698-1736
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 4DATE:
12/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mary MalekamuTIME COMPLETED:
05:30 PM
NARRATIVE
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On 12/23/2021 Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a case management inspection due to another visit. LPA met with S2, Administrator lived at second floor of the facility, LPA met Administrator after 15mins. LPA explained the purpose of the visit to Administrator Mary Melakamu.

LPA toured facility inside and outside. LPA observed 4 residents in care, 3 are on hospice.

The following was observed during facility visit:

- Disinfectants supplies observed accessible with residents in care.- Cleared

V1,V2,V3 V4,F1 & F2 observed at the facility do not have fingerprint clearance.

- S2 do not have fingerprint exemption clearance.

- LPA observed facility sitting area (per facility sketch) is cluttered with clothes, shoes on the floor, bedroom #3 & bedroom #5 was observed to have a lot of unorganized clothes, shoes on the floor, pantry which is located at the dining area is unorganized with food supplies observed to be on the floor.

- LPA observed 1.5 Gallon of milk and ¾ bag loaf of bread during the visit, LPA asked Administrator to show residents food supplies, Administrator showed freezer located at the garage, LPA observed frozen food but not for residents, Administrator confirmed that frozen food are not fore residents, LPA asked if there are more available perishable food for residents, Administrator showed refrigerator located at the kitchen area, LPA observed more food supplies for staff/visitors.

...Continue to LIC809C...

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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: 12/23/2021
NARRATIVE
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LPA interviewed Administrator if all the visitors (V1,V2,V3 V4,F1 & F2) observed during LPA visit followed covid19 guidelines based on PIN 21-40-ASC, Administrator admitted that visitation policy was not followed, all visitors are not properly screened for covid19 symptoms, vaccine and covid19 test results , any covid19 symptoms are not documented , according to Administrator all visitors that was observed during the visit has been at the facility for 1 week. (technical assistance provided)

$3,500.00 Civil penalty was assessed during the visit.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.



Exit interview conducted. Appeal Rights and a copy of this report was provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC809 (FAS) - (06/04)
Page: 2 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2021
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review...prior to working, residing or volunteering in a licensed facility: Obtain a California clearance...
This requirement is not met as evidence by:
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Based on observation and interview 5 adults visitors has been staying at the facility with no fingerprint clearance, this possess immediate health and safety risk for residents in care.
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Type B
12/23/2021
Section Cited

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87705 Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances...
This requirement is not met as evidence by:

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Based on observation, facility failed to keep cleaning supplies and disinfectant inaccessible to residents in care, This possess an immediate health and safety risk of residents.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2021
LIC809 (FAS) - (06/04)
Page: 3 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2021
Section Cited

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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by
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Based on observation LPA observed facility sitting area (per facility sketch) is cluttered with clothes, shoes on the floor, bedroom #3 & bedroom #5 was observed to have a lot of unorganized clothes, shoes on the floor, pantry which is located at the dining area is unorganized with food supplies observed to be on the floor. This possess a potential health and safety risk of residents.
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Type B
12/27/2021
Section Cited

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General Food Service Requirements
Supplies of nonperishable foods for a minimum of one week.. shall be maintained on the premises
This requirement was not met as evidenced by
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Based on observation and interview, 1.5 Gallon of milk and ¾ bag loaf of bread during the visit, LPA asked Adminsitrator if there are more perishable food for resident, Adminsitrator only showed eggs observed at the counter. This possess a potential health and safety risk of residents.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2021
LIC809 (FAS) - (06/04)
Page: 4 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2021
Section Cited

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Criminal Record Clearance
Obtain a California clearance or a criminal record exemption as required by the Department...
This requirement is not met as evidence by:
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Based on investigation, licensee did not comply with the section cited above by having S2 who do not have fingerprint exemption clearance work at the facility which poses an immediate health and safety risk to the clients in care.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5