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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201099
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:24:35 AM

Document Has Been Signed on 08/03/2022 11:24 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GARCIA'S PLACE, INC.FACILITY NUMBER:
079201099
ADMINISTRATOR:GAVILAN, LOIDAFACILITY TYPE:
735
ADDRESS:1712 SAN JOSE DRIVETELEPHONE:
(925) 565-5731
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 3DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Josselyn Ruiz, CaregiverTIME COMPLETED:
11:30 AM
NARRATIVE
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On 8/23/2022 at 10:15AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Josselyn Ruiz, Caregiver. Caregiver called Administrator and LPA explained the purpose of the visit. Administrator, Loida Gavilan arrived at 10:33AM.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, backyard, and kitchen. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 107.4 degrees Fahrenheit. Fire extinguisher last serviced on 7/19/2021. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Infection Control Plan on file. LPA observed food and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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: GARCIA'S PLACE, INC.
FACILITY NUMBER: 079201099
VISIT DATE: 08/03/2022
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Continued from LIC809.

The following deficiency was observed:

-At 10:20AM, LPA observed S2 was not able to communicate with client or LPA.

LPA request the following documents to be submitted to CCLD by 8/10/2022.

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610D Emergency Disaster Plan

The following deficiency were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2022 11:24 AM - It Cannot Be Edited


Created By: Laura Hall On 08/03/2022 at 10:58 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: GARCIA'S PLACE, INC.
FACILITY NUMBER: 079201099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(3)
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

(3) Provision of client care and supervision, including communication.

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 S2 being able to communicate with clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Administrator agreed to review regulation 80065 and submit a self-certification that the regulation has been reviewed and facility will abide by the regulation. Self-certification shall be submitted to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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