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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201011
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:48:58 PM

Document Has Been Signed on 01/12/2023 01:48 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:THOMAS HOMEFACILITY NUMBER:
079201011
ADMINISTRATOR:DELA CRUZ, RONNELFACILITY TYPE:
735
ADDRESS:1000 THOMAS CTTELEPHONE:
(917) 750-5856
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Ronaldo Guinto, CaregiverTIME COMPLETED:
01:55 PM
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On 01/12/2023 at 12:55PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met Ronaldo Guinto, Caregiver, and explained the reason for the visit. Co-Administrator, Jeffrey Meimban, arrived at 1:15PM.

Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 sign was posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 110.4 degrees Fahrenheit. Fire extinguisher last serviced on 11/5/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods.

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

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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: THOMAS HOME
FACILITY NUMBER: 079201011
VISIT DATE: 01/12/2023
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Continued from LIC809.
  • LPA request facility's LIC500.

The following deficiency was observed:

-At 1:10PM, LPA observed car exit gated located on right side of house was locked with padlock, and pedestrian gate on left side of house had padlock but was unlocked.

The following deficiency was observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

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

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/12/2023 01:48 PM - It Cannot Be Edited


Created By: Laura Hall On 01/12/2023 at 01:29 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: THOMAS HOME
FACILITY NUMBER: 079201011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(7)
80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or not.

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 exit gates with padlocks, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2023
Plan of Correction
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Co-Administrator agreed to remove padlocks from both gates. Padlocks were removed immediately during visit. Deficiency cleared.
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: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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