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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200997
Report Date: 11/22/2022
Date Signed: 11/22/2022 12:56:54 PM


Document Has Been Signed on 11/22/2022 12:56 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: 2DATE:
11/22/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Chioma "Abigail" Okpara, AdministratorTIME COMPLETED:
01:05 PM
NARRATIVE
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On 11/22/20222 at 10:25AM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint. LPAs met with Chioma "Abigail" Okpara, Administrator and explained the reason for the visit.

Upon arrival, LPAs observed total of two (2) staff and one two (2) residents in the facility. LPAs was informed that one (1) resident was in the hospital and one (1) resident has been transferred to a skilled nursing and is not returning.

During the health and safety check, LPAs toured the building with Administrator including but not limited to common areas, bathrooms, and bedrooms. Facility is noted to be clean and in good repair and residents in care appear to be safe. There are no imminent health/safety concerns on today's date.

LPAs observed the following deficiencies:

- Resident files for R1, R2, R3, and R4 were incomplete.
- Administrator did not submit an incident report for R1 and R2

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report, LIC9098, and appeal rights provided

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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 2


Document Has Been Signed on 11/22/2022 12:56 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: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2022
Section Cited

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87506 Resident Records
(a) The licensee shall ensure that a... complete, and current record is maintained for each resident...
This requirement was not met as evidence by:
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Based on LPAs record review and observation, Licensee did not comply with the section cited above in having residents records complete, which poses a potential health and safety risk to persons in care
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Type B
11/29/2022
Section Cited

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87211 (a) Each licensee shall furnish to the licensing agency such reports...
(1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events...
This requirement was not met as evidence by:
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Based on LPAs record review and observation, the licensee did not comply with the section cited above, in reporting incident to CCLD, which poses a potential health and safety risk to persons in care.
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the regulation going forward by the POC date.
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: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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