015600471-7-18-2024-15-AS-CFOR-D7AS5C-20240718133407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600471
Report Date: 07/18/2024
Date Signed: 07/18/2024 01:34:23 PM

Document Has Been Signed on 07/18/2024 01:34 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:	ANDREW ELIJAHS GUEST HOME		FACILITY NUMBER:	015600471
ADMINISTRATOR:	JUNTILLA, ANDREW ELIJAH C		FACILITY TYPE:	740
ADDRESS:	1234 PURDUE STREET		TELEPHONE:	(510) 614-2285
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94579
CAPACITY:	6	CENSUS: 6	DATE:	07/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	MARIA THERESA, CAREGIVER		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-year required visit on 7/18/2024 at 9:50am. LPA met and toured with Caregiver, Maria Theresa. Administrator, Alex Juntilla arrived at 11:20am. The Administrator currently holds a certificate (#6020375740) that expires on 11/17/2024. The facility’s fire clearance was approved for 6 non-ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 2 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared residents bathroom was measured at 110.7 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke detector were not in operating condition, Carbon monoxide detector was in operating condition. Fire extinguishers were last serviced on 10/22/2023. Emergency Disaster Plan was last posted on 10/22/2023. First aid kit was observed to be complete. LPA reviewed 4 staff files. All files were incomplete . LPA reviewed 5 resident files and all were found to be incomplete. Report continues on 809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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 07/18/2024 01:34 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: ANDREW ELIJAHS GUEST HOME	FACILITY NUMBER: 015600471
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 in having a smoke detector not in operable condition which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to replace the battery or smoke detector and submit self certification by the POC date.

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 in having cleaning solutions such as Comet, Purell Clean, Fabuloso in an unlocked cabinet in the bathroom which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to keep all chemicals/clean solutions locked at all times. 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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: ANDREW ELIJAHS GUEST HOME	FACILITY NUMBER: 015600471
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 the door frame and cabinet next to the dishwasher in disrepair which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to replace/repair doorframe and area next to dishwasher and submit photos to the Department by the POC date.

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by having staff working with expired CPR/First Aid training which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/31/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have all staff CPR/First Aid training updated and submit a copies of completion to the Department by the 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2024 01:34 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: ANDREW ELIJAHS GUEST HOME	FACILITY NUMBER: 015600471
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not having residents medical assessments conducted yearly which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have all residents medical assessments completed and submit copies to the Department by the POC date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not conducting disaster drills and not having documentation which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Administrator agreed to conduct an emergency disaster/fire drill and submit proof to the Department by the 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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: ANDREW ELIJAHS GUEST HOME	FACILITY NUMBER: 015600471
	VISIT DATE: 07/18/2024

NARRATIVE

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CONTINUE FROM LIC 809

LPAs observed the following deficiencies:
- at 10:25am. LPA observed Comet, Purell Cleaner, Fabuloso.
- at 10:35am. LPA observed medication in an unlocked drawer located in the kitchen.
- at 10:40am. LPA observed door frame and side of dishwasher in disrepair.
- at 10:45am, LPA observed smoke detector not working.
-at 10:48am, LPA observed staff has expired CPR/First Aid training.
-at 10:50am, LPA observed residents files incomplete.
-at 10:53am, LPA observed facility has not conducted a fire/emergency disaster drill.

The following 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.

The following forms to be updated and submitted to CCL by 07/25/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 610E Emergency Disaster Plan

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

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