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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200997
Report Date: 10/01/2024
Date Signed: 10/01/2024 05:54:50 PM


Document Has Been Signed on 10/01/2024 05:54 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:FAM CARE HOMES, LLCFACILITY NUMBER:
079200997
ADMINISTRATOR:OKPARA, CHIOMA ABIGAILFACILITY TYPE:
740
ADDRESS:1502 PEPPERTREE PLACETELEPHONE:
(925) 481-4397
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 3DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Chioma Okpara, AdministratorTIME COMPLETED:
06:15 PM
NARRATIVE
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On 10/1/2024 at 3:15pm, Licensing Program Analysts (LPAs) L. Hall and D. Doidge conducted an unannounced annual required inspection. LPAs met with Administrator, Chioma "Abigail: Okpara, and explained the purpose of the visit. The Administrator holds a certificate 7020776740 which expires on 10/30/2025. The facility’s fire clearance is approved for six (6) non-ambulatory residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) bedrooms and three (3) bathrooms. One (1) bedroom is occupied by staff. No bodies of water was observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 128.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 11/7/2023. Emergency Disaster Plan was last posted on 12/30/2024. First aid kit was observed to be complete. Fire drill was last conducted on 09/2/2024.

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
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 4


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: FAM CARE HOMES, LLC
FACILITY NUMBER: 079200997
VISIT DATE: 10/01/2024
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Continued from LIC809.

LPAs reviewed two (2) staff both were current and complete. LPAs also reviewed three (3) client files and all were missing the appraisal needs and services plan.

LPA observed the following deficiencies:
  • At 3:20pm, LPAs observed a surface bolt lock and padlock on the front door.
  • At 3:45pm, LPAs observed during record review all three (3) residents were missing the appraisal needs and services.

LPA requested the following documents to be submitted to CCLD by 10/8/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (last page)
  • Liability Insurance


*An immediate $500.00 civil penalty will be assessed on today's date for fire safety*

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due date, and any repeat violations within 12-month period may result in civil penalties.



Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/01/2024 05:54 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: FAM CARE HOMES, LLC
FACILITY NUMBER: 079200997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having an appraisal needs and services plan for each resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
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Administrator agreed to create an appraisal needs and services plan for each resident and submit documents to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/01/2024 05:54 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: FAM CARE HOMES, LLC
FACILITY NUMBER: 079200997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(6)
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.

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 padlock and surface bolt lock on the front door which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2024
Plan of Correction
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Administrator agreed to remove both locks and submit a photo of the door 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4