079201079-7-13-2022-15-AS-LIBO-CGARBN-20220713125301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201079
Report Date: 07/13/2022
Date Signed: 07/13/2022 12:53:17 PM

Document Has Been Signed on 07/13/2022 12:53 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:	TERESA'S QUALITY COMFORT CARE, LLC		FACILITY NUMBER:	079201079
ADMINISTRATOR:	BOATNER, SALINA		FACILITY TYPE:	740
ADDRESS:	1786 CONCANNON DR		TELEPHONE:	(925) 206-1947
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 5	DATE:	07/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Salina Boatner, Administrator/Licensee		TIME COMPLETED:	01:10 PM

NARRATIVE

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On 7/13/2022 at 10:00 AM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required infection control inspection. LPA met with Administrator Salina Boatner. Facility has census of 5.

LPA toured the entire premises indoors and outdoors. The facility has 3 bedrooms, 2 bathrooms, one story house per facility sketch. 3 bedrooms are designated for residents only. LPA observed 1 fire extinguisher which located at the garage. Smoke detectors and carbon monoxide detectors were observed operational.

LPA observed adequate lighting. Hallways and passageways were free of obstructions. Food supplies were sufficient good for 7 days of non-perishables. Linens, bed covers, hygiene and paper product supplies were observed. Knives are kept in a locked cabinet. Laundry supplies are locked in cabinets in the laundry area. First aid kit checked and showed complete with manual. No bodies of water observed.

...Continued to LIC809C...

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

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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Document Has Been Signed on 07/13/2022 12:53 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TERESA'S QUALITY COMFORT CARE, LLC	FACILITY NUMBER: 079201079
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(d)(5)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in LPA observed that S3 does not have proof of infection prevention training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/15/2022
	Plan of Correction
1 2 3 4	Administrator agreed to send proof of training for S3 via email by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

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: TERESA'S QUALITY COMFORT CARE, LLC	FACILITY NUMBER: 079201079
	VISIT DATE: 07/13/2022

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Facility has enough paper supplies and hygiene supplies. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE (mask)

LPA conducted technical assistance on the following topics:

Infection control plan to be submitted to CCL by 7/15/2022, PIN was provided to Administrator.
LPA recommended to Administrator to modify visitors covid19 screening question.
LPA discussed with Administrator about reporting requirements.
LPA discussed with Administrator about visitation guidelines and latest PINs.
LPA discussed with Administrator the importance of N95 Fit testing (technical assistance provided).
LPA recommended to add more PPE supplies.
LPA provided Contra costa SPOT link for covid19 reporting.
All staff needs training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control. LPA observed that S3 does not have proof of infection prevention training.

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.

Deficiencies and plan and proof of corrections were discussed with Salina Boatner.

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC809 (FAS) - (06/04)

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