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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201045
Report Date: 02/25/2023
Date Signed: 02/25/2023 02:19:18 PM

Document Has Been Signed on 02/25/2023 02:19 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:SG FACILITYFACILITY NUMBER:
079201045
ADMINISTRATOR:GRAN, SECINANDOFACILITY TYPE:
735
ADDRESS:990 JENSEN CIRCLETELEPHONE:
(925) 308-3316
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 2DATE:
02/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Isidro Avila, CaregiverTIME COMPLETED:
02:25 PM
NARRATIVE
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On 2/25/2023 at 1:00PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Isidro Avila, Caregiver, and explained the purpose of the visit. LPA spoke with Licensee Aidole Gran via telephone. Co-Administrator, Monique Gran, arrived at 1:25PM. Administrator Secinando Gran arrived at 2:05PM.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were 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 129.0 degrees Fahrenheit. Fire extinguisher last serviced on 6/22/2022. LPA observed 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: 02/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2023
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: SG FACILITY
FACILITY NUMBER: 079201045
VISIT DATE: 02/25/2023
NARRATIVE
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Continued from LIC809.

LPA request the following documents to be submitted to CCLD by 3/6/2023:
  • LIC500 (Personnel record)

LPA observed the following deficiencies:
  • At 1:20PM, LPA observed shed in backyard being used for staff resting/sleeping.
  • At 1:30PM, LPA observed hot water temperature at 129.0 degrees F.


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

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

DATE: 02/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/25/2023 02:19 PM - It Cannot Be Edited


Created By: Laura Hall On 02/25/2023 at 01:51 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: SG FACILITY
FACILITY NUMBER: 079201045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 the hot water temperature between 105 - 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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Administrator agreed to adjust hot water temperature and submit photo of new temperature 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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/25/2023 02:19 PM - It Cannot Be Edited


Created By: Laura Hall On 02/25/2023 at 01:53 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: SG FACILITY
FACILITY NUMBER: 079201045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities

(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in notifying CCLD about alteration which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
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Administrator agreed to submit new facility sketch and LIC200 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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2023


LIC809 (FAS) - (06/04)
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