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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200934
Report Date: 10/15/2021
Date Signed: 10/22/2021 11:02:04 AM

Document Has Been Signed on 10/22/2021 11:02 AM - 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:GRAYSON HOME, THEFACILITY NUMBER:
079200934
ADMINISTRATOR:HAWKINS, MONIQUEFACILITY TYPE:
735
ADDRESS:2436 CARDINAL CTTELEPHONE:
(925) 207-0229
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 6CENSUS: 6DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Cecilia HawkinsTIME COMPLETED:
04:32 PM
NARRATIVE
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator (ADM) Cecilia Hawkins. LPA inspected the facility inside and outside. All of the staff and residents were fully vaccinated. ADM is the designated Infection control leader. LPA observed that 2 of the 2 staff present wore face masks at all times. However, when the husband (Nicholas "Nick" Hawkins) of the ADM was serving as a volunteer in the facility, he was not wearing a mask until the LPA instructed him to do so, which he subsequently did.

The LPA observed a screening station located near the front entrance with only hand sanitizer and a no-touch temperature gage. There was no visitor's log, face masks, nor examination or recording of vaccination status for staff, residents, or visitors. LPA observed COVID-19 signs posted in common areas to promote hand washing and physical distancing. Facility does not document daily temperature or health status for staff or residents. The LPA discussed the mitigation plan with the ADM, as well as their current COVID-19 infection control practices. Though ADM had conducted staff training on infection prevention, symptoms, transmission, as well as the proper donning and doffing of PPE in the past when they had a Covid-19 outbreak at their other facility, they were not following a whole host of Infection Control practices, including:

- Routine symptom check (in addition to temperature check) must be conducted and recorded for each person visiting the facility.
- Not following PIN 21-40-ASC with Visitor COVID-19 Vaccination verification from any of the visitors who entered the facility.
- Not documenting symptoms on a daily basis.
- No specific procedures for testing, isolating, quarantining, or accepting clients back from hospital.
- Training inadequate and not keeping up-to-date with the latest Licensing requirements from the Department.

-------Continued on 809-C-----------
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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 14
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: GRAYSON HOME, THE
FACILITY NUMBER: 079200934
VISIT DATE: 10/15/2021
NARRATIVE
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There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper and PPE supplies were observed. Facility room temperature was maintained at a comfortable temperature.

A certified administrator is on site at all times to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged and last inspected in June 2021 and the Smoke and Carbon monoxide detectors were fully operational.

LPA observed two (2) Type A deficiencies and one (1) Type B deficiencies, the details of which are in the LIC809-D citations.

Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 10/22/2021 11:02 AM - It Cannot Be Edited


Created By: James Sampair On 10/15/2021 at 01:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRAYSON HOME, THE
FACILITY NUMBER: 079200934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 because the water temperature was 140 degrees Farenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2021
Plan of Correction
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Temperature of water must be decreased to safe zone of 105 to 120 degrees Farenheit.
Type A
Section Cited
CCR
1522(b)(1)
1522(b)(1) Fingerprints and criminal records
An individual shall be required to obtain either a criminal record clearance or a criminal record exemption from the State Department of Social Services before his or her initial presence in a community care facility or certified family home.
(b) (1) In addition to the applicant, this section shall be applicable to criminal record clearances and exemptions for the following persons:
(D) Any staff person, volunteer, or employee who has contact with the 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, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2021
Plan of Correction
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Associate Nicholas "Nick" Hawkins or not allow him to again volunteer at the facility.
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 Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 10/22/2021 11:02 AM - It Cannot Be Edited


Created By: James Sampair On 10/15/2021 at 01:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRAYSON HOME, THE
FACILITY NUMBER: 079200934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights (a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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 complying with PIN 21-40-ASC concerning vaccination restrictions and recording that information accordingly, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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Administrator must have written procedures for staff to check and then to record the vaccination status for each visitor that has been sent to LPA.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
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