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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200924
Report Date: 12/09/2022
Date Signed: 12/09/2022 03:18:46 PM


Document Has Been Signed on 12/09/2022 03:18 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
E BAY DELTA AC/SC, 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:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Mary Malekamu, AdministratorTIME COMPLETED:
03:35 PM
NARRATIVE
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On 12/09/2022 at 1:35 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Administrator, Mary Malekamu and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility with Mary including but not limited to front entrance, screening station, bathrooms, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient two day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, and hand washing posters were observed. Common touched surfaces are disinfected at least once daily.
Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30 day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan. Smoke and carbon monoxide detectors are interconnected with sprinkler system. First Aid kit was complete. LPA observed facility passages inside and out free of obstruction.

The following deficiency was observed during inspection:
-At approximately 2:30 PM LPA observed that the fire extinguishers were last serviced April 2021

The following deficiencies were observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties

Exit interview conducted and a copy of this report provided along with Appeal rights.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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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Document Has Been Signed on 12/09/2022 03:18 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
E BAY DELTA AC/SC, 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: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


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 failure to have fire extinguishers serviced on an annual basis which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that fire extinguishers were last serviced April 2021.
POC Due Date: 12/30/2022
Plan of Correction
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Administrator will have fire extinguishers serviced and send photographic proof to CCL by POC date.
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: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
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