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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201186
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:38:14 PM

Document Has Been Signed on 08/30/2023 04:38 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:OAKRIDGE HOME- WRENFACILITY NUMBER:
079201186
ADMINISTRATOR:NUBLA, MIKEFACILITY TYPE:
735
ADDRESS:3460 WREN COURTTELEPHONE:
(925) 436-3921
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 3DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ann Marielle Llaguna, CaregiverTIME COMPLETED:
04:45 PM
NARRATIVE
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On 8/30/2023 at 1:15pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Ann Marielle Llaguna, Caregiver, and explained the purpose of the visit. Administrator, Mike Nubla, arrived at 03:00pm. The administrator currently holds a certificate (#6021845735) that expires on 11/17/2023. The facility’s fire clearance was approved for five (5) non-ambulatory and 1 bedridden client.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) 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 98.8 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 5/26/2022. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: OAKRIDGE HOME- WREN
FACILITY NUMBER: 079201186
VISIT DATE: 08/30/2023
NARRATIVE
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Continued from LIC809.

Three (3) staff records were reviewed upon arrival of Administrator. All three (3) clients' records reviewed and incomplete. LPA reviewed P&I.

The following forms to be updated and submitted to CCLD by 9/11/2023:
  • LIC610D Emergency disaster plan (last page)
  • Liability insurance.
  • Surety Bond
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources


The following deficiencies were observed during visit:
  • At 1:30pm, LPA observed during record review that all three (3) clients files were incomplete.
  • At 1:30pm, LPA observed during record review P&I was not available at the facility.
  • At 1:40pm, LPA observed during record review that staff files were not present to inspect.
  • At 1:45pm, LPA observed the facility did not have a supplies of non-perishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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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: OAKRIDGE HOME- WREN
FACILITY NUMBER: 079201186
VISIT DATE: 08/30/2023
NARRATIVE
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Continued from LIC809C.

The following 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. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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Document Has Been Signed on 08/30/2023 04:38 PM - It Cannot Be Edited


Created By: Laura Hall On 08/30/2023 at 04:12 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: OAKRIDGE HOME- WREN
FACILITY NUMBER: 079201186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 have 7 days of non perishable and 2 days of perishable foods available for clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2023
Plan of Correction
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Administrator agreed to purchase food and submit copies of receipts and photos of food to CCLD by POC date.
Type B
Section Cited
CCR
80026(j)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents

(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having cash resources on facility premises which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2023
Plan of Correction
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Administrator will submit copies of safeguards for cash resource documents 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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


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Document Has Been Signed on 08/30/2023 04:38 PM - It Cannot Be Edited


Created By: Laura Hall On 08/30/2023 at 04:19 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: OAKRIDGE HOME- WREN
FACILITY NUMBER: 079201186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(c)
80070 Client Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having client records completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2023
Plan of Correction
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Administrator will submit a self-certification to CCLD by POC date stating client files are complete.
Type B
Section Cited
CCR
80066(e)(1)
80066 Personnel Records

(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having staff files available to inspect which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2023
Plan of Correction
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Administrator agreed to have staff files available to inspect when needed. Administrator brought staff files to inspect during visit. Deficiency cleared during visit.
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
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


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