019200878-4-2-2024-15-AS-AGOZ-D3XS3Q-20240402133129

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200878
Report Date: 04/02/2024
Date Signed: 04/02/2024 01:32:32 PM

Document Has Been Signed on 04/02/2024 01:32 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	WILLIAMS FAMILY CARE HOME		FACILITY NUMBER:	019200878
ADMINISTRATOR:	WILLIAMS, GLADYS G		FACILITY TYPE:	740
ADDRESS:	674 GLENEAGLE AVENUE		TELEPHONE:	(510) 441-1180
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	6	CENSUS: 4	DATE:	04/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	01:50 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 4/2/2024 at 9:30 AM, Licensing Program Analysts (LPAs) A. Gomez and A Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Florentina Natnat and explained the purpose of the visit. Backup Administrator John Williams arrived at 10:30 AM. The facility’s fire clearance was approved for 6 non-ambulatory. LPAs toured facility with Backup Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 5 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 117.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 2/20/2023. First aid kit was observed to be complete. At 9:40 AM, LPAs reviewed 4 residents records. At 10;00AM AM, LPAs reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. LPA's are requesting that R1 receives a new physicians report and appraisal of needs and services based on observation of residents condition. LPA's advised administrator that their fire extinguisher recently expired. Report continues LIC809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WILLIAMS FAMILY CARE HOME	FACILITY NUMBER: 019200878
	VISIT DATE: 04/02/2024

NARRATIVE

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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:45 AM during file review LPA's observed that R3's physicians report stated that they are bedridden. R3 is not on hospice. Facility is not cleared for bedridden. (Immediate $500 Civil Penalty)
At 11:06 AM during tour LPA's observed an unlocked knife in kitchen located in cabinet above the oven.
At 12:30 PM Administrator was unable to locate disaster drill log

****An immediate $500 civil penalty is being assessed on todays date****

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 04/11/2024:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (9 pages)
Current Administrator’s Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email due to printer complications.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/02/2024 01:32 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WILLIAMS FAMILY CARE HOME	FACILITY NUMBER: 019200878
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons 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 aboveby R3 being bedridden when the facility is not cleared for bedridden which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	By POC date Administrator agrees to get R3 a new physicians report and submit a copy to CCLD.

Type A

Section Cited

CCR

87309(a)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 an unsecured , unlocked knife in kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Caregiver removed and locked away knife.

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-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/02/2024 01:32 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WILLIAMS FAMILY CARE HOME	FACILITY NUMBER: 019200878
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2024

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not having any updated drills on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to update drills and log and notify CCLD.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

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