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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201065
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:06:29 PM

Document Has Been Signed on 04/06/2022 04:06 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:OAKLEY ASSISTED LIVING II , LLCFACILITY NUMBER:
079201065
ADMINISTRATOR:LAKE, NICOLETTEFACILITY TYPE:
740
ADDRESS:1449 BUTTONS CTTELEPHONE:
(925) 219-6165
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Nicollete Lake, Administrator TIME COMPLETED:
04:30 PM
NARRATIVE
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On 4/6/2022 at 12:50PM , Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Shirley Virden, staff. Administrator Nicolette Lake arrived at the facility after 20 mins. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 72 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.


Continued on next page LIC 809-C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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: OAKLEY ASSISTED LIVING II , LLC
FACILITY NUMBER: 079201065
VISIT DATE: 04/06/2022
NARRATIVE
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The following was observed and deficiency was cited:

· V1 is not fingerprint cleared, staff an Administrator stated that V1 has been coming to the facility couple of times a week and interact with residents in care.
· S4 was not associated at the facility.
· Soap pods was unlocked and accessible to residents in care
· Medications was observed prepared at least 5 days in advance and was not in the original container.

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

A $500.00 civil penalty was assessed during today's visit.

Deficiencies and plan and proof of corrections were discussed with Nicolette Lake.

Exit interview conducted and a copy and appeal rights of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/06/2022 04:06 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/06/2022 at 03:05 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: OAKLEY ASSISTED LIVING II , LLC
FACILITY NUMBER: 079201065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility

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 which LPA observed V1 (Volunteer) is not fingerprint cleared and assisting residents during LPA visit, Administrator admitted that V1 visits the facility couple times in a week which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2022
Plan of Correction
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By POC date, Administrator will obtain fingerprint clearance for V1 and submit a self-certification letter acknowledging V1 is not to provide care for residents until clearance and a copy of live scan to CCL.

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 LPA observed soap pods are unlocked and accessible to residents in care which poses an immediate health and safety risk to person in care.
POC Due Date: 04/06/2022
Plan of Correction
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Administrator agreed to have soap pods lock to a cabinet that will be inaccessible to residents in care. Cleared and corrected.
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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/06/2022 04:06 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/06/2022 at 03:16 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: OAKLEY ASSISTED LIVING II , LLC
FACILITY NUMBER: 079201065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance Request a transfer of a criminal record clearance as specified in Section…
This requirement is not met as evidence by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above in which S4 is not associated to the facility which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 04/07/2022
Plan of Correction
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Administrator will associate S4 at the facility within 24hrs.
Type B
Section Cited
CCR
87465(h)(5)
87465 Incidental Medical and Dental Care (h) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 which LPA observed medications for all residents was prepared at least five days in advance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Licensee shall train all staff and review regulation regarding Incidental Medical and Dental Care and submit to licensing by POC date, a self certified letter verifying that licensee understands the importance of not transferring resident's medications from original containers and not to prepare it more than 24hrs in advance.
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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


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