079201079-7-18-2024-15-AS-TSGN-D7ATHN-20240718144502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201079
Report Date: 07/18/2024
Date Signed: 07/18/2024 02:45:13 PM

Document Has Been Signed on 07/18/2024 02:45 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
OAKLAND ASC, 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: 2	DATE:	07/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:56 AM
MET WITH:	Lashawna Barrett, Caregiver		TIME COMPLETED:	02:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/18/2024 at 10:56 AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Lashawna Barrett, Caregiver and explained the purpose of the visit. Lashawna contacted the Administrator via telephone to advise of my visit. Administrator arrived at approximately 12:10PM. Administrator currently holds a certificate (#7034204740) expires 04/05/2026. The facility’s fire clearance was approved for four (4)non ambulatory and one (1) bedridden residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of three (3) bedrooms and two (2) 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 80 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 106.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and nonskid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 10/23/2023. Emergency Disaster Plan was last posted on 10/09/2023. First aid kit was observed to be complete. Fire drill conducted on 05/13/2024 Continued LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 3 of 13

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: TERESA'S QUALITY COMFORT CARE, LLC	FACILITY NUMBER: 079201079
	VISIT DATE: 07/18/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809.

LPA reviewed two (2) resident records and two (2) staff records, and they were current and complete. LPAs also reviewed medications.

LPA observed the following deficiencies:

At 11:42AM LPA observed unlocked sharps in kitchen pantry cabinet with child safety latch
At 11:43AM LPA observed window cleaner in an unlocked cabinet under the kitchen sink
At 11:50AM LPA observed laundry detergent unlocked in the garage

The following forms to be updated and submitted to CCLD by 07/25/2024:

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· Liability Insurance
· Current Administrator’s Certificate

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 of the appeal rights and this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

Page: 9 of 13

Document Has Been Signed on 07/18/2024 02:45 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
OAKLAND ASC, 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: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having knives in an unlocked cabinet in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Caregiver immediately removed knives and placed in a locked cabinet. Deficiency cleared during visit.

Type A

Section Cited

CCR

87309

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having window cleaner under kitchen sink in a unlocked cabinet, Laundry detergent in garage unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to purchase an appropriate lock for the garage door and send pictures 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

Page: 10 of 13