079201102-10-7-2021-15-AS-JSAR-C7KW3S-20211007165626

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201102
Report Date: 10/07/2021
Date Signed: 10/07/2021 05:01:24 PM

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:	DYSICO CARE HOME, RCFE		FACILITY NUMBER:	079201102
ADMINISTRATOR:	LEKSE, EVANGELINE		FACILITY TYPE:	740
ADDRESS:	461 TURRIN DRIVE		TELEPHONE:	(925) 270-3081
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 4	DATE:	10/07/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Josephine Dysico and Evangeline Lekse		TIME COMPLETED:	05:30 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	Licensing Program Analyst (LPA) James Sampair conducted an unannounced pre-licensing inspection and met with Applicant, Josephine Dysico and Administrator, Evangeline Lekse. LPA explained the reason for the visit. LPA observed 4 staff wearing masks. LPA also observed 4 residents eating meals, resting in their bedrooms, and watching television during the visit. LPA toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. There is sufficient lighting around the facility. Resident's rooms were equipped with the proper furniture and lighting. Resident's rooms had proper bedding and linens. Bathrooms were equipped with grab bars, nonskid mats, and hygiene items. Living room is equipped with the proper furniture for the residents. All toxins and sharp objects were locked. Passageways and hallways were free of obstruction. Fire extinguisher is fully charged. Smoke and Carbon Monoxide detectors were operational. Medication cabinet was locked and first aid kit was complete. Exit doors are equipped with auditory signals. Hot water temperature was measured at 110 degrees F. Sufficient 2 day perishable and 1 week non-perishable food supplies were observed in the refrigerator, freezer, garage, and additional food supplies were observed in the garage freezer. Complaint poster, personal rights, Ombudsman and rights to council posters were observed displayed near the dining area. LPA did observe seven (7) Technical Violations during the inspection: one (1) Physical Plant/Environmental Safety, one (1) Residents with Special Health Needs, and one (1) Disaster Preparedness. The facility is not ready to be licensed. -------Continued on 809-C-----------

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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: DYSICO CARE HOME, RCFE	FACILITY NUMBER: 079201102
	VISIT DATE: 10/07/2021

NARRATIVE

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The Licensee must complete the following before this report will be submitted to the central application unit (CAU), where a final review of the application will be conducted:

1. Provide proof that adequate emergency lighting has been placed in easily accessible locations for the residents of the facility at its maximum capacity.

2. Update the Emergency and Disaster Plan to include:
(a) Methods for meeting the needs of residents with special needs, such as dementia and hospice services.
(b) Proof that supplies and equipment mentioned in the plan have been purchased and included in "To Go Bags" and an "Emergency Kit" which includes but is not limited to: a generator able to supply the power necessary to care for all residents and staff when at maximum capacity with light, heat, cooling, refrigeration of medicines; and an adequate supply of bottled water.
(c) Multiple transportation providers
(d) Include procedures for confirming the location of residents during an emergency or disaster.

3. Complete LIC 999 Facility Sketch (Yard) and add the Resident Assembly Point to it.

This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

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