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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201102
Report Date: 10/18/2024
Date Signed: 10/18/2024 04:51:11 PM

Document Has Been Signed on 10/18/2024 04:51 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, RCFEFACILITY NUMBER:
079201102
ADMINISTRATOR/
DIRECTOR:		LEKSE, EVANGELINEFACILITY TYPE:
740
ADDRESS:461 TURRIN DRIVETELEPHONE:
(925) 270-3081
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 5DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Evangeline Lekse, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 10/18/2024 at 12:45 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Evangeline Lekse and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) non-ambulatory. Hospice waiver for two (2). Administrator certificate #6024122740 expires 03/08/2025.

LPA toured facility with Evangeline including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which six (6) bedrooms are occupied by the residents and one (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’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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 6
Document Has Been Signed on 10/18/2024 04:51 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 10/18/2024 at 03:46 PM
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: DYSICO CARE HOME, RCFE
FACILITY NUMBER: 079201102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above in by not having CPR training for S1-S3 which poses a potential health and safety risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Administrator agreed to submit CPR training for S1-S3 to CCLD by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in by not having 20hrs annual training for S2 and S3 which poses a potential health, and safety risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator agreed to submit completed training certificates for S2 and S3 to CCLD by POC due date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/18/2024 04:51 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 10/18/2024 at 03:46 PM
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: DYSICO CARE HOME, RCFE
FACILITY NUMBER: 079201102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in by not having a doctor's order on file for R5 half-rail hospital bed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator agreed to submit a doctor's order for R5's 1/2 rail hospital bed for mobility, postural support and submit to CCLD by POC due date.
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in by not notifying local fire dept in writing that oxygen is in use in bedroom #3/R4 which poses a potential health and safety risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Administrator agreed to submit a copy of letter sent to local fire department and to place a copy of letter in R4's file to CCLD by POC due date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


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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: 10/18/2024
NARRATIVE
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LIC809-C Continued...

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 09/10/2024. Emergency Disaster Plan was last posted on 04/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/20/2024.

LPA reviewed five (5) residents records. LPA reviewed three (3) staff records and 3 of 3 have current first aid training and associated to the facility.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/25/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan - Reviewed
Liability Insurance

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/18/2024 04:51 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 10/18/2024 at 04:33 PM
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: DYSICO CARE HOME, RCFE
FACILITY NUMBER: 079201102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87623(b)(2)
87623 Indwelling Urinary Catheter

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(2) Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in by having documentation on file for R1's foley catheter which poses a potential health and safety risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator agree to submit an exception request letter with supporting documents: Physician's Report, Doctor's Order, Appraisal Needs and Services that outlines in detail who is caring for the catheter and what care is the staff provided with the catheter. In addition, what training has the staff had and who was the licensed health professional that conducted the training. All documents should be submitted to CCLD by POC due 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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
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