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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200724
Report Date: 01/25/2023
Date Signed: 01/25/2023 03:23:36 PM


Document Has Been Signed on 01/25/2023 03:23 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:GRAND LAKE HOMEFACILITY NUMBER:
019200724
ADMINISTRATOR:GUINTO, VERONICA BFACILITY TYPE:
740
ADDRESS:365 STATEN AVENUETELEPHONE:
(510) 893-5308
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:14CENSUS: 13DATE:
01/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Veronica Guinto, AdministratorTIME COMPLETED:
03:35 PM
NARRATIVE
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On 1/26/23 at 2:25 p.m., Licensing Program Analyst (LPA) C. Lin conducted case management, met with Administrator (AD), and explained the purpose of visit.

During the course of investigation on a complaint, the Department observed the following deficiencies:

· R2 has no needs & service plan (LIC625) on file.

· R3’s needs & service plan (LIC625) was not updated annually. The latest update was dated on 2/27/20.

· R2 was admitted to hospital on 9/5/22 and R3 was admitted to hospital on 7/29/22, no unusual incident report (LIC624) for both residents were reported to CCL.

Deficiencies are cited per Title 22 California Code of Regulations. Please refer to LIC 809D. Failure to submit proof of correction by plan of correction due date and/or any repeat violation within 12 month period may result in civil penalty.

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

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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 01/25/2023 03:23 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GRAND LAKE HOME
FACILITY NUMBER: 019200724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2023
Section Cited

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87506 Resident Records
(b) Each resident’s record shall contain at least the following information:
(17) Documents and information required by the following:
(E) Section 87463, Reappraisals;
This requirement is not met as evidenced by…

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Administrator agrees to review and understand regulation and submit a self-certification of being in compliance in future events to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed resident R2 has no appraisal/needs and services plan (LIC625) on file which poses/posed a potential health, safety or personal rights risk to persons in care.

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Type B
02/01/2023
Section Cited

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87463 Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident’s representative…once every 12 months...
This requirement is not met as evidenced by…
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Administrator agrees to review and understand regulation and submit a self-certification of being in compliance in future events to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed resident R3 has no updated appraisal/needs and services plan (LIC625) on file which poses/posed a potential health, safety or personal rights risk to persons in care.

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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/25/2023 03:23 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GRAND LAKE HOME
FACILITY NUMBER: 019200724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2023
Section Cited

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87211 Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports…(1)A written report shall be submitted to the licensing agency… (D) Any incident which threatens the welfare, safety or health of any resident…
This requirement is not met as evidenced by…

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Administrator agrees to review Sec 87211 Reporting Requirements and submit self-certification of understanding to CCL by the POC due date.
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Based on record review and interview, Licensee did not comply with the regulation cited above. Facility did not submit incident report (LIC624) when R2 and R3 were sent to hospital for medical attention which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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