019200896-12-16-2023-15-AS-CFOR-CYKSSR-20231216130821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200896
Report Date: 12/16/2023
Date Signed: 12/16/2023 01:08:34 PM

Document Has Been Signed on 12/16/2023 01:08 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:	CASA SAN LORENZO		FACILITY NUMBER:	019200896
ADMINISTRATOR:	HOSAIN, MARIA LUISA		FACILITY TYPE:	740
ADDRESS:	171 VIA LINARES		TELEPHONE:	(510) 329-9300
CITY:	SAN LORENZO	STATE: CA	ZIP CODE:	94580
CAPACITY:	6	CENSUS: 4	DATE:	12/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Genoveva Torres, Caregiver		TIME COMPLETED:	02:45 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 12/16/2023 at 9:11am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Genoveva Torres, and Eloisa Guevara Caregivers, and explained the purpose of the visit. The Administrator currently holds a certificate (#6010517740) that expires on 02/10/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by staff. No bodies of water observed. A comfortable temperature is maintained at 73 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 120.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/6/2023. First aid kit was observed to be complete. LPA reviewed four (4) of four residents files and four (4) of four (4) staff files, which were all complete. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

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 12/16/2023 01:08 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: CASA SAN LORENZO	FACILITY NUMBER: 019200896
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 pre-poured medication which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/18/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will submit a written statement of having read and understood the regulation and conducted in-service training with all staff, providing CCLD with a copy of all signatures of staff attended no later than the POC date.

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: CASA SAN LORENZO	FACILITY NUMBER: 019200896
	VISIT DATE: 12/16/2023

NARRATIVE

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Continued from LIC809.

LPA observed the following deficiencies:

· At 11:45am, LPA observed pre-poured medication.

LPA requested the following documents to be submitted to CCLD by 12/27/2023.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

Last Disaster Drill Conducted Document

Based on LPA observations and interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

LIC809 (FAS) - (06/04)

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