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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201040
Report Date: 05/14/2024
Date Signed: 05/14/2024 01:55:31 PM


Document Has Been Signed on 05/14/2024 01:55 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CATHEDRAL CARE HOMEFACILITY NUMBER:
079201040
ADMINISTRATOR:DATUIN, MARIVICFACILITY TYPE:
740
ADDRESS:2707 CATHEDRAL CIRCLETELEPHONE:
(925) 222-8492
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Hubert Omaguing, CaregiverTIME COMPLETED:
02:05 PM
NARRATIVE
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On 05/14/2024 at 10:25AM, Licensing Program Analysts (LPA) T.Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Hubert Omaguing, spoke with Administrator Marivic Datuin via telephone, and explained the purpose of the visit. The Administrator currently holds a certificate (#6056346740) that expires on 06/14/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms and four (4) bathrooms two (2) bedrooms used for staff. LPA did not observe any bodies of water. A comfortable temperature is maintained at 76 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 116.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and no skid mats. 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 03/24/2024. Emergency Disaster Plan was last posted on 11/15/2023. First aid kit was observed to be complete. Fire drill was last conducted on 04/15/2024?.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CATHEDRAL CARE HOME
FACILITY NUMBER: 079201040
VISIT DATE: 05/14/2024
NARRATIVE
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Continued from LIC809.

LPA reviewed three (3) resident records and three (3) staff records, S2 and S3 missing Health Screening

LPA requested the following documents to be submitted to CCLD by 05/21/2024:

· LIC 200 and Updated Facility Sketch
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report (Updated with Administrator available hours during normal business hours)
· LIC 610E Emergency Disaster Plan

LPA observed the following deficiencies:

· At 10:36AM LPA observed unlocked drawer in kitchen with knives
· At 10:45AM LPA observed unlocked drawer in rooms #3 and #4 joint bathroom with scissors
· At 11:14AM LPA observed unlocked cabinet with medication
· At 11:20AM LPA observed unlocked closet in garage with laundry detergent
· At 1:00PM LPA observed during personnel record review S2 and S3 missing Health Screening

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. A copy of this report and appeal rights provided.

Continue on LIC809D

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/14/2024 01:55 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: CATHEDRAL CARE HOME
FACILITY NUMBER: 079201040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 knives in an unlocked kitchen drawer accessible to residents with dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Caregiver immediately locked kitchen drawer with knives. Deficiency cleared during visit
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 laundry detergent in the unlocked garage and unlocked shed in the backyard with gardening supplies which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Caregiver removed Laundry detergent to a cabinet with a lock during visit. Deficiency cleared
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: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 05/14/2024 01:55 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: CATHEDRAL CARE HOME
FACILITY NUMBER: 079201040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 medications in an unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Caregiver immediately locked cabinet with medications 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 05/14/2024 01:55 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: CATHEDRAL CARE HOME
FACILITY NUMBER: 079201040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(2)(C)
87307 Personal Accommodations and Services
(2) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads.... The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair.....

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 residents not having top bed sheets which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2024
Plan of Correction
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Administrator agreed to place top sheets on residents bed and send a photo of complete bedding by email to CCLD by POC date.
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
(11) A health screening as specified in Section 87411, Personnel Requirements - General.

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 in not having S2 and S3 Health Screening available during personnel record review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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Administrator agreed to send an email with photos of health screening for S2 and S3 to CCLD by 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: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6