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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601425
Report Date: 12/07/2023
Date Signed: 12/07/2023 02:02:58 PM


Document Has Been Signed on 12/07/2023 02:02 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:HEATHER'S CARE HOMEFACILITY NUMBER:
015601425
ADMINISTRATOR:VEGA-CAJUCOM, MICHELLE MFACILITY TYPE:
740
ADDRESS:3279 LANGHORN DRIVETELEPHONE:
(510) 648-2461
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY:6CENSUS: 6DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jonas DepasupilTIME COMPLETED:
02:15 PM
NARRATIVE
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On 12/7/2023 at approximately 10:15 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with Jonas Depasupil, Administrator.
The facility is a Level 4C home vendorized by the Regional Center of the East Bay (RCEB). The facility has an approved fire clearance for six non ambulatory clients.

LPA with Depasupil inspected the facility inside and out including but not limited to three client bedrooms, two bathrooms, kitchen, common areas, garage and backyard. All outdoor and indoor passageways are kept free of obstruction. There were no bodies of water observed. LPA observed medications were locked in a cabinet in the hallway. Chemicals were locked in the garage.

LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the kitchen was measured at 116 degrees Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. Hygiene items, extra linens and toiletry supplies were checked and observed sufficient. Fire extinguisher was last serviced on 12/15/22, smoke detectors and carbon monoxide were operational. Last fire drill was conducted on 8/30/23. First aid kit was inspected and observed complete. Food supplies were sufficient to meet 2-day perishable and 7-day non-perishable requirements.

At 11: 30 am LPA reviewed five(5) client files and four (4) staff files. All staff have criminal record clearance and are associated to the facility. At 1pm, P&I monies were reviewed with the Administrator. Facility was unable to provide surety bond during the visit.
continuation on Lic 809C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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: HEATHER'S CARE HOME
FACILITY NUMBER: 015601425
VISIT DATE: 12/07/2023
NARRATIVE
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Administrator states that the facility has a $5,000 surety bond and will submit a copy to LPA with Lic 400 by Dec 8, 2023.

The following deficiencies were observed:
  • at around 10:40am, LPA observed screen doors ripped or have tiny holes
  • last fire drill was conducted on August 30, 2023

The following forms were provided to LPA during the visit:
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Copy of liability insurance
Car insurance/registration/copy of driver's license

Deficiencies were cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview was conducted with Depasupil. Appeal Rights and a copy of this report were provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 12/07/2023 02:02 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: HEATHER'S CARE HOME
FACILITY NUMBER: 015601425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)


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 screen doors that are ripped/with tiny holes which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2023
Plan of Correction
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By POC date, Administrator states all screen windows which are tipped/with tiny holes will be replaced. Photo proof will be sent to CCL.
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 12/07/2023 02:02 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: HEATHER'S CARE HOME
FACILITY NUMBER: 015601425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on file review, the licensee did not comply with the section cited above in not having an updated fire drill which poses/posed a potential health, safety or personal rights risk to persons in care. Last fire drill was conducted on August 30, 2023.
POC Due Date: 12/14/2023
Plan of Correction
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Administrator states facility will conduct fire drill for the quarter and submit proof of training to CCL 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4