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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201065
Report Date: 04/09/2024
Date Signed: 04/22/2024 09:37:24 AM

Document Has Been Signed on 04/22/2024 09:37 AM - 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:OAKLEY ASSISTED LIVING II , LLCFACILITY NUMBER:
079201065
ADMINISTRATOR/
DIRECTOR:		LAKE, NICOLETTEFACILITY TYPE:
740
ADDRESS:1449 BUTTONS CTTELEPHONE:
(925) 219-6165
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Niesha Lewisn CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 04/09/2024 at 1:30PM, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an unannounced 1-Year Required inspection. LPM Harpreet Humpal was also present.. LPA met with Caregiver Niesha, spoke with Administrator, Nicolette Lake via telephone, and explained the purpose of the visit. The Administrator arrived at 1:45PM and c) that expires on 08/07/2024. The facility’s fire clearance was approved for four (4) non-ambulatory and two (2) bedridden residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 75 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 111.6 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 serviced on 09/06/2023. Emergency Disaster Plan was last posted on 02/07/2024. First aid kit was observed to be complete Fire drill was last conducted on 01/07/2024.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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: OAKLEY ASSISTED LIVING II , LLC
FACILITY NUMBER: 079201065
VISIT DATE: 04/09/2024
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Continued from LIC809.

LPA reviewed three (3) residents files they were all complete. Three (3) staff records, one (1) staff was missing health screening, First Aid/CPR and training. LPA reviewed a sample of medications.

LPA observed the following deficiencies:

· At 2;15pm, LPAs observed R1 in room two(2) with hospital bed with rail.
· At 2:34pm, LPA observed S3 missing CPR/First Aid and Training for dementia.

Deficiencies were 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.


LPA requested the following documents to be submitted to CCLD by 04/16/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report (updated)
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance


Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2024 09:37 AM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 04/09/2024 at 03:51 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: OAKLEY ASSISTED LIVING II , LLC
FACILITY NUMBER: 079201065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

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 a doctor's order for Resident having a hospital bed with rail ,which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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2
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Administrator agreed to submit an email to CCLD of the doctor orders for bed rail by POC date.
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:

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 staff Healt Screen document, training for residents with demetia and Firdt AId/CPR which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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Adminstrator agreed to submit email of Health screen , First AId/CPR and training for care of residents with dementia for 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 Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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