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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200947
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:53:18 PM

Document Has Been Signed on 01/27/2023 12:53 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:AIM HIGHFACILITY NUMBER:
079200947
ADMINISTRATOR:TRUCKS, CHRISTINAFACILITY TYPE:
775
ADDRESS:1336 SUNSET DRTELEPHONE:
(415) 290-7611
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 30CENSUS: 25DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Tiara NIx, Direct Support Professional (DSP)TIME COMPLETED:
01:00 PM
NARRATIVE
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On 1/27/2023 at 11:35AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Tiara Nix, Direct Professional (DSP), and explained the purpose of the visit. DSP, Alberto Vega arrived at 11:55AM. LPA spoke with Administrator, Christina Trucks for document signing approval..

Upon entry, LPA's temperature was not checked. LPA observed screening station that contained hand sanitizer and sign-in log but not a temperature log. LPA toured facility including but not limited to common areas and bathrooms. All hand washing stations were equipped with soap, and paper towel, and hand washing poster. Fire extinguishers purchased 1/7/2023. LPA observed there was not hot water in either shared clients' bathroom.

During record review, LPA observed facility has a copy of the infection control plan on file. LPA observed PPE and paper supplies are sufficient.

The following deficiency was observed:

-At 12:35PM, LPA observed facility not having any hot water.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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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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: AIM HIGH
FACILITY NUMBER: 079200947
VISIT DATE: 01/27/2023
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Continued from LIC809.

The following forms are to be updated and submitted to CCLD by 2/3/2023:
  • Emergency Disaster Plan
  • Personnel Record (LIC500)
  • Administrator certificate


Exit interview conduct. A a copy of this report provided and appeal rights provided..
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2023 12:53 PM - It Cannot Be Edited


Created By: Laura Hall On 01/27/2023 at 12:42 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: AIM HIGH
FACILITY NUMBER: 079200947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(1)
82088 Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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 in having hot water in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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Administrator agreed to install or have existing water heater repaired, and submit photo showing hot water temperature to CCLD 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023


LIC809 (FAS) - (06/04)
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