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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201071
Report Date: 04/09/2024
Date Signed: 04/22/2024 09:36:03 AM

Document Has Been Signed on 04/22/2024 09:36 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:PICADILLY HOME CAREFACILITY NUMBER:
079201071
ADMINISTRATOR/
DIRECTOR:		SANTOS, CHARLIEFACILITY TYPE:
735
ADDRESS:1221 PICADILLY LANETELEPHONE:
(925) 849-7743
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 4CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:21 AM
MET WITH:Matthew Tobas AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 04/09/24 at 9:21AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Administrator Matthew Tobas and explained the purpose of the visit. Licensee Charlie Santos arrived at 9:30 AM. The Administrator currently holds a certificate (#6033319740) . Facility has census of 4. LPA observed two (2) clients. The facility’s fire clearance was approved for four (4) ambulatory residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) 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 66 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 113.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. 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 serviced on 10/09/2023. Emergency Disaster Plan was last posted on 06/02/2022. First aid kit was observed to be complete. Fire drill was last conducted on 03/19/2024.

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: PICADILLY HOME CARE
FACILITY NUMBER: 079201071
VISIT DATE: 04/09/2024
NARRATIVE
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Continued from LIC809.

Four (4) staff records were reviewed. LPA reviewed all four (4) resident records, and they were current and complete. LPA reviewed samples of medication.


LPA requested the following documents to be submitted to CCLD by 04/17/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 610E Emergency Disaster Plan (last page)
· Liability Insurance

LPA observed the following deficiencies:
  • AT 9:29AM, LPA observed unlocked cabinet with medication in the kitchen.
  • AT 9:45 LPA observed no signal system in clients rooms on second floor.



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 the appeal rights, LIC421BG, and the report 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)
Page: 2 of 4
Document Has Been Signed on 04/22/2024 09:36 AM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 04/09/2024 at 11:58 AM
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: PICADILLY HOME CARE
FACILITY NUMBER: 079201071

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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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4
Based on observation, the licensee did not comply with the section cited above in not having medication locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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2
3
4
Caregiver immediately locked medication during visit. Deficiency cleared.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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)
Page: 3 of 4
Document Has Been Signed on 04/22/2024 09:36 AM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 04/09/2024 at 12:02 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: PICADILLY HOME CARE
FACILITY NUMBER: 079201071

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(f)(2)
85088 Fixtures, Furniture, Equipment and Supplies
(f) Facilities shall meet the following signal system requirements:
(2) Facilities having more than one wing, floor or building shall be allowed to have a separate signal system in each component provided that each such system meets the criteria specified in (1)(A) through (C) above

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 not having a signal system for clients on second floor 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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Admnistrator purchased signal system during visit. LPA verified proof of purchase. Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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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