079201127-2-17-2023-15-AS-LFRO-CP633T-20230217165404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201127
Report Date: 02/17/2023
Date Signed: 02/17/2023 04:54:18 PM

Document Has Been Signed on 02/17/2023 04:54 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:	ALAMO RESIDENCE HOME		FACILITY NUMBER:	079201127
ADMINISTRATOR:	ENRIQUEZ, JOY MANALANG		FACILITY TYPE:	740
ADDRESS:	2978 MIRANDA AVE		TELEPHONE:	(408) 449-8044
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	6	CENSUS: 5	DATE:	02/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Joy Enriquez, Administrator		TIME COMPLETED:	05:05 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 2/17/2023 starting at 3:05 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Joy Enriquez and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility with Administrator including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. At 4:00 PM, LPA reviewed 3 staff records and observed 3 of 3 staff have health screening with TB test results on file. Facility has a mitigation plan and maintains record of routine screening for staff. THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT -At approximately 3:35 PM, LPA observed unlocked lighter fluid in the backyard. Deficiency cleared during visit. Administrator locked lighter fluid in the garage. *REPORT CONTINUES ON 809C*

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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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Document Has Been Signed on 02/17/2023 04:54 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: ALAMO RESIDENCE HOME	FACILITY NUMBER: 079201127
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having lighter fluid unlocked and accessible in the backyard which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/18/2023
	Plan of Correction
1 2 3 4	Deficiency cleared during visit. LPA observed Administrator lock lighter fluid away in the garage. In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures to CCLD by 2/24/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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: ALAMO RESIDENCE HOME	FACILITY NUMBER: 079201127
	VISIT DATE: 02/17/2023

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 2/24/2023

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

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

Exit interview conducted. Appeal Rights and a copy of this report provided to Administrator.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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