079201102-9-20-2023-15-AS-LAWN-CVV2RT-20230920173805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201102
Report Date: 09/20/2023
Date Signed: 09/20/2023 05:38:15 PM

Document Has Been Signed on 09/20/2023 05:38 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:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:41 AM
MET WITH:	Evangeline Lekse, Administrator/Caregiver		TIME COMPLETED:	04:20 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 11:41 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Administrator/Caregiver, Evangeline Lekse, and explained the purpose of the visit. Evangeline's Administrator Certificate# 6024122740 Expired 03/08/2023. Evangeline is waiting for a renewal certificate to arrive. The facility’s fire clearance was approved for 6 non-ambulatory. Also the facility has a Hospice Waiver for 2 Residents. LPA toured facility with Evangeline including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 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’ 2 shared bathrooms was measured at 109.0, 111.2/111.0 (double sink) degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. LIC809-C Continued...

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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LIC809 Continued...

There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 09/14/2023. Emergency Disaster Plan was last posted on 07/20/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/20/2023.

At 12:30PM, LPA reviewed 6 Residents records. At 2:30 PM, LPA reviewed 7 staff records and 6 of 7 have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/27/2023:

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

No deficiencies cited during visit. Exit interview conducted and a copy of this report 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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