019200515-7-20-2023-15-AS-GLUK-CTWV5J-20230720160801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200515
Report Date: 07/20/2023
Date Signed: 07/20/2023 04:08:08 PM

Document Has Been Signed on 07/20/2023 04:08 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:	ABIGAIL'S GUEST HOME		FACILITY NUMBER:	019200515
ADMINISTRATOR:	AURELIA MENDOZA		FACILITY TYPE:	740
ADDRESS:	6372 ARLINGTON DRIVE		TELEPHONE:	(925) 216-2921
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94566
CAPACITY:	6	CENSUS: 5	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Carlota Moises, Caregiver		TIME COMPLETED:	04:15 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	On 7/20/2023 at 11:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Caregiver, Carlota Moises and explained the purpose of the visit. 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 8/30/2022. One week of nonperishable and 2-day of perishable food supplies were available. Hot water was measured at 110.5 degrees F. 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. Indoor and outdoor passageways were free of obstruction. No bodies of water observed. LPA reviewed 5 resident records starting at 1:10PM. At 1:50PM, LPA observed R2 does not have a current needs and service plan and 3 out of 5 residents does not have a current medical assessment. At 1:55PM, LPA observed 4 out of 5 residents does not have TB test results on file. At 2:00PM, LPA observed 4 out of 5 residents does not have pre-placement appraisals on file. (Continue on LIC809C...)

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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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Document Has Been Signed on 07/20/2023 04:08 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: ABIGAIL'S GUEST HOME	FACILITY NUMBER: 019200515
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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 by not having pre-placement appraisals for 4 out of 5 residents which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Facility has agreed to review regulation and create a written plan to obtain pre-placement appraisals for future residents. Facility will submit the written plan to CCLD by POC date.

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 by not having TB test results for 4 out of 5 residents which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain TB test results for R2, R3, R4, and R5. Facility will submit the TB test results 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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: ABIGAIL'S GUEST HOME	FACILITY NUMBER: 019200515
	VISIT DATE: 07/20/2023

NARRATIVE

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At 2:50PM, LPA observed not all staff files were available during record review.

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

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

Exit interview conducted. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/20/2023 04:08 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: ABIGAIL'S GUEST HOME	FACILITY NUMBER: 019200515
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. 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 by not having current medical assessments and a current reappraisal for residents which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain current medical assessments for R2, R3, and R5 and obtain current reappraisal for R2. Facility will submit updated medical assessments and reappraisal to CCLD by POC date.

Type B

Section Cited

CCR

87412(f)

(f) All personnel 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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having staff files available during annual inspection which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Facility has agreed to have all staff files including administrator's file available at the facility for future inspections. Facility will submit self-certification 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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