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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201147
Report Date: 07/05/2024
Date Signed: 07/05/2024 12:56:55 PM


Document Has Been Signed on 07/05/2024 12:56 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ALAMO CARE HOMEFACILITY NUMBER:
079201147
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:2795 MIRANDA AVE.TELEPHONE:
(925) 413-3578
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 6DATE:
07/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Caregiver, Voichita StoicaTIME COMPLETED:
01:15 PM
NARRATIVE
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On 7/05/2024 at approximately 12:30PM, while at the facility on an unrelated complaint investigation LPA A Gomez conducted a case management visit.

LPA A Gomez observed a black kitchen knife, and 3 pairs of scissors in the kitchen unsecured.

1 type A deficiency is being issued.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
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 07/05/2024 12:56 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ALAMO CARE HOME
FACILITY NUMBER: 079201147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2024
Section Cited
CCR
87705(f)(1)

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(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 evidence by:
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Caregiver locked away dangerous items.
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Based on observation the Licensee did not comply with the above regulation by having accessible scissors, and knife which poses an immediate health and safety risk to persons in care.
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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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
LIC809 (FAS) - (06/04)
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