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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201267
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:47:02 PM

Document Has Been Signed on 09/12/2024 04:47 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:CAMKRIS TOTAL CARE HOME LLCFACILITY NUMBER:
079201267
ADMINISTRATOR/
DIRECTOR:		TABONES, FELOMENAFACILITY TYPE:
740
ADDRESS:5017 SAINT GARRETT COURTTELEPHONE:
(925) 664-1941
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 4DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Felomena Tabones, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 9/12/2024 at 10:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Amankai Pomee and explained the purpose of the visit. Administrator, Felomena Tabones arrived 45 minutes later.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 9/10/2024. One week of nonperishable and 2-day of perishable food supplies were available. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete.

LPA reviewed 4 residents and 3 staff files starting at 12:15PM. LPA reviewed a sample of resident's medications during inspection. LPA interviewed 2 residents and 2 staff during inspection.

At 11:22AM, LPA measured hot water temperature at 133.3 degrees F in the hallway bathroom. Administrator has lowered hot water and LPA re-measured hot water at 120 degrees F.

At 11:30AM, LPA observed unlocked gardening tools (shovel, rack, axe) in the backyard. Staff locked up the items during inspection.

At 12:00PM, LPA observed two resident's rooms have baby monitor inside and the receiver was located in the living room area. Staff removed the baby monitors during inspection.

(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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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: CAMKRIS TOTAL CARE HOME LLC
FACILITY NUMBER: 079201267
VISIT DATE: 09/12/2024
NARRATIVE
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At 1:20PM, LPA observed residents records and staff records were incomplete. LPA was informed that some records were at a different location and not at the facility.

LPA will return at a later time to complete annual inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 09/12/2024 04:47 PM - It Cannot Be Edited


Created By: Grace Luk On 09/12/2024 at 03:37 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: CAMKRIS TOTAL CARE HOME LLC
FACILITY NUMBER: 079201267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above by having hot water at 133.3 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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4
Administrator has lowered hot water and LPA re-measured hot water at 120 degrees F.

Deficiency cleared.
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
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2
3
4
Based on observation, the licensee did not comply with the section cited above by having unlocked gardening tools in the backyard which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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2
3
4
Staff locked up the gardening tools (shovel, rack, axe) during inspection.

Deficiency cleared.
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:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2024 04:47 PM - It Cannot Be Edited


Created By: Grace Luk On 09/12/2024 at 04:00 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: CAMKRIS TOTAL CARE HOME LLC
FACILITY NUMBER: 079201267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above by having baby monitors in two resident's rooms which poses a potential personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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2
3
4
Staff have removed the baby monitors in room 1 and room 4 during inspection.

Deficiency cleared.
Type B
Section Cited
CCR
87506(d)
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having incomplete files for residents which poses a potential health and safety risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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2
3
4
Administrator has agreed to obtain all resident's complete files and have it available at the facility for any future reviews. Administrator will submit a written statement 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:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2024 04:47 PM - It Cannot Be Edited


Created By: Grace Luk On 09/12/2024 at 04:18 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: CAMKRIS TOTAL CARE HOME LLC
FACILITY NUMBER: 079201267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

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 by having incomplete files for staff which poses a potential health and safety risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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2
3
4
Administrator has agreed to obtain all staff's complete files and have it available at the facility for any future reviews. Administrator will submit a written statement to CCLD by POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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