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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200940
Report Date: 06/24/2022
Date Signed: 06/24/2022 03:47:47 PM


Document Has Been Signed on 06/24/2022 03:47 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:NEW ALAMO RESIDENCE HOMEFACILITY NUMBER:
079200940
ADMINISTRATOR:SAXENA, MEERANFACILITY TYPE:
740
ADDRESS:836 STONE VALLEY RDTELEPHONE:
(925) 743-1565
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 6DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Meeran Saxena, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On 6/24/2022 at 12:25 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPA was greeted by Care Staff, Irene Joseph. Administrator, Meeran Saxena later arrived at 12:40 PM.

During the Infection Control Inspection, LPA toured facility with Administrator including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station Social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff.

During record review, LPA reviewed 3 staff records and 3 of 3 have health screening and TB test results on file. Facility has a mitigation plan on file.

THE FOLLOWING DEFICIENCY HAS BEEN OBSERVED
  • At 1:15 PM, during record review and interview, S1 has been employed since March 2022, and no vaccination exemption on file is maintained in accordance to Public Health Order and PIN 22-05.1-ASC
  • At 1:20 PM, during record review, weekly COVID-19 testing is not being conducted for S1 according to Public Health Order on September 28, 2021 and PIN 21-32.1-ASC


REPORT CONTINUES ON 809C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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 9


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: NEW ALAMO RESIDENCE HOME
FACILITY NUMBER: 079200940
VISIT DATE: 06/24/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/1/2022:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • Current Administrator’s Certificate


The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Administrator authorized Care Staff, Irene Joseph to sign report.

Exit interview conducted with Care Staff. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 06/24/2022 03:47 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: NEW ALAMO RESIDENCE HOME
FACILITY NUMBER: 079200940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)(2)
87405(d)(2) Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

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. S1 does not have an exemption for COVID-19 on file and weekly COVID-19 testing is not being conducted in accordance to Public Health Order and PIN 22-05.1-ASC which poses a potential health and safety risk to persons in care..
POC Due Date: 07/08/2022
Plan of Correction
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By POC, Administrator will submit a plan to CCLD indicating whether S1 will have an exemption on file or obtain COVID-19 vaccination and a self-certification letter that a weekly COVID-19 testing will be completed for S1 in according to Public Health Order and PIN 22-05.1-ASC and PIN 21-32.1-ASC
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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