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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201102
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:41:27 PM


Document Has Been Signed on 09/21/2022 04:41 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:DYSICO CARE HOME, RCFEFACILITY NUMBER:
079201102
ADMINISTRATOR:LEKSE, EVANGELINEFACILITY TYPE:
740
ADDRESS:461 TURRIN DRIVETELEPHONE:
(925) 270-3081
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 6DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Evangeline Lekse, AdministratorTIME COMPLETED:
04:50 PM
NARRATIVE
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On 9/21/2022 at 3:25PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Evangeline Lekse, and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs posted near screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Hot water temperature in the shared clients’ bathroom was measured at 119.9 degrees Fahrenheit. Fire extinguisher last serviced on 9/1/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed facility has a copy of the mitigation plan on file. LPA observed PPE, food, and paper supplies are sufficient.

The following deficiencies were observed:
  • At 3:31PM, LPA observed knife drying in dish rack on kitchen counter.
  • At 3:45PM, during observation and record review LPA observed R2, R3, and R6 does not have a doctor's order for their hospital bed.


Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: 09/21/2022
NARRATIVE
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Continued from 809.

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

Exit interview conducted. A copy of this report provided and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/21/2022 04:41 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: DYSICO CARE HOME, RCFE
FACILITY NUMBER: 079201102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 having a knife inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Administrator immediatley removed knife from dish rack and locked it in a locked kitchen drawer. Deficiency cleared during visit.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/21/2022 04:41 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: DYSICO CARE HOME, RCFE
FACILITY NUMBER: 079201102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.

(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review) the licensee did not comply with the section cited above in having a doctor's order for a hospital bed for R2, R3, and R6 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator agreed to get a doctor's order for the hospital beds and submit a copy 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4