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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200995
Report Date: 11/21/2022
Date Signed: 11/21/2022 11:57:19 AM


Document Has Been Signed on 11/21/2022 11:57 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CAREFRONT RESIDENTIAL LIVING, LLCFACILITY NUMBER:
079200995
ADMINISTRATOR:WANG, DINGFACILITY TYPE:
740
ADDRESS:4086 TULARE DRTELEPHONE:
(925) 890-8953
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ding Wang, LincenseeTIME COMPLETED:
11:55 AM
NARRATIVE
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On 11/21/2022 at 9:10 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Administrator/Licensee, Ding Wang and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility with Ding including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient two day perishable and one week non-perishable food supply. 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. 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 PPE maintained at central location and easily accessible for staff. Facility has a mitigation plan. Smoke and carbon monoxide detectors were observed. First Aid kit was complete. LPA observed facility passages inside and out free of obstruction.

The following deficiency was observed during inspection:
-At approximately 10:25 AM LPA observed that S1 was not associated to the facility

The following deficiencies were observed (see LIC 809D) 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: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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 11/21/2022 11:57 AM - 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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or


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 by not associating S1 to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2022
Plan of Correction
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Adminstrator will have another caregiver work instead of S1 until the complete a transfer. Administrator will email and call CCL to complete the criminal record clearance transfer and associate them to the facility. Administrator will send proof of transfer completion 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: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
LIC809 (FAS) - (06/04)
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