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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201166
Report Date: 05/04/2024
Date Signed: 05/04/2024 02:14:44 PM


Document Has Been Signed on 05/04/2024 02:14 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:FLOWERING PLUMS ASSISTED LIVINGFACILITY NUMBER:
079201166
ADMINISTRATOR:BALANANDAN, PRAMODFACILITY TYPE:
740
ADDRESS:591 FLOWERING PLUM PLTELEPHONE:
(510) 331-5774
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 6DATE:
05/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Wilfredo Abarra CaregiverTIME COMPLETED:
02:20 PM
NARRATIVE
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On ##/##/## at 10:00am, Licensing Program Analyst (LPA)T.Syess-Gibson conducted an unannounced annual 1-Year required inspection. LPA met with Wilfredo Abarra, Caregiver, and explained the purpose of the visit. Administrator, Pramod Balanandan, arrived at 11:18AM. The administrator currently holds a certificate (#6050378740) that expires on 01/16/2025. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility with caregiver, Wilfredo Abarra, including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of six (6) total bedrooms and two (2 ) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 101.9 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 08/31/2023. Emergency Disaster Plan was last posted on 12/15/2023. Fire drill last conducted 01/17/2024. First aid kit was observed to be complete.

Continued on LIC809C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2024
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


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: FLOWERING PLUMS ASSISTED LIVING
FACILITY NUMBER: 079201166
VISIT DATE: 05/04/2024
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Continued from LIC809.

Four (4) staff records were reviewed, and all staff have first aid certification. All six (6) clients' records reviewed, current, and complete.

The following forms to be updated and submitted to CCLD by 05/11/2024:

· Liability insurance.
· LIC500 (Personnel Record)
· LIC9020 (Client Roster)
· LIC308 (Designation of facility Responsibility)
· LIC400 (Affidavit Regarding Client/Resident Cash Resources)
· LIC610E (Emergency Disaster Plan)

LPA observed the following deficiencies:
  • At 10:56AM LPA observed Clorox toilet cleaner under sink in common bathroom
  • At 11:00AM LPA observed not all of the residents has the signal system in bedrooms
  • At 12:24PM LPA observed during file review (R4) physician report states bedridden and facility isn't approved on fire clearance for bedridden residents

Continued on LIC809C

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: FLOWERING PLUMS ASSISTED LIVING
FACILITY NUMBER: 079201166
VISIT DATE: 05/04/2024
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Continued from LIC809C


*The total amount of civil penalties assessed on today's date is $500.00 for Fire Clearance


Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report, LIC421IM and the appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/04/2024 02:14 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: FLOWERING PLUMS ASSISTED LIVING
FACILITY NUMBER: 079201166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a signal system in all residents rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2024
Plan of Correction
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Administrator agreed to having signal system in all the residents rooms and submit an email of the receipt of purchase and photos to CCLD by poc 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 05/04/2024 02:14 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: FLOWERING PLUMS ASSISTED LIVING
FACILITY NUMBER: 079201166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having cleaning supply in an unlocked cabinet accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2024
Plan of Correction
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Caregiver immediately removed the Clorox toilet cleaner and stored it in the locked laundry room. Deficiency cleared during visit
Type A
Section Cited
CCR
87202(a)(2)
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(2) Bedridden persons
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a bedridden resident, which hasn't been approved per the facility's fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2024
Plan of Correction
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Administrator agreed to submit a request for a change of capacity LIC200 and Updated Facility Sketch to CCLD by poc 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6