079201102-9-20-2023-15-AS-LAWN-CVV2ST-20230920173941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201102
Report Date: 09/20/2023
Date Signed: 09/20/2023 05:39:45 PM

Document Has Been Signed on 09/20/2023 05:39 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
E BAY DELTA AC/SC, 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: 6	DATE:	09/20/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	04:21 PM
MET WITH:	Evageline Lekse, Administrator/Caregiver		TIME COMPLETED:	05:50 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 09/20/2023 at 4:21PM, Licensing Program Analyst (LPA), L. Alexander conducted an unannounced Case Management in regard to a phone call from Staff (S1), regarding one of the Residents. S1 called LPA L. Alexander on 09/18/2023 with concerns for R1 because they have been drinking alcohol (Vodka) and not eating. S1 had concerns that R1 may have symptoms of alcohol withdrawal and that the Staff would not be able to handle that type of issue if it occurred. S1 says that R1 was admitted earlier to their facility under hospice care and that the Physician's Report (LIC602) did not say that there was any type of alcohol/substance abuse. The hospice agency (HA) was allowing R1 to consume alcohol. R1 was discharged from hospice on 07/21/2023. The updated LIC602 dated 09/13/2023 includes to question #13 and #14: (f) Substance Abuse Problem - yes, and (g) Use of Alcohol -yes (2.5L in 24hrs). Question#14 (c) Aggressive Behavior - yes (when intoxicated). S1 was concerned for compliance as well that R1 may be harming herself because she isn't eating much. There is a doctor's order with restrictions for R1, "R1 should not drink any alcohol."

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DYSICO CARE HOME, RCFE	FACILITY NUMBER: 079201102
	VISIT DATE: 09/20/2023

NARRATIVE

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LPA spoke with R1 during "Client Interview" while conducting an Annual Inspection today. R1 says that she doesn't really go out in the main common area. R1 says that she doesn't eat much because she just doesn't eat. However, R1 says that she orders her own snacks (chips, salsa, water, seltzer drinks, etc) through Instacart and that's how she receives her delivered items. R1 has a instant ice maker and Keurig coffee maker in her private room. Today, R1 says that she ate a hotdog today for lunch but probably won't eat anything else.

LPA requested and received documents for R1:

Physician's Report LIC602; dated 06/05/2023
Physician's Report LIC602; dated 09/15/2023
Kaiser's Activity Status Report; dated 09/13/2023

(doctor's order with restrictions no alcohol)

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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