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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440165
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:28:36 PM


Document Has Been Signed on 05/17/2023 03:28 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:ABRAHAM REST HOMEFACILITY NUMBER:
071440165
ADMINISTRATOR:ABRAHAM, SARAFACILITY TYPE:
740
ADDRESS:116 VIA MONTETELEPHONE:
(925) 944-5218
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
05/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Annette SanchezTIME COMPLETED:
03:45 PM
NARRATIVE
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On 05/17/2023 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Case Management visit regarding the deficiencies he identified during his 05/16/2023 complaint inspection. The LPA met with Administrator (ADM) Annette Sanchez.

During the visit, the LPA toured the facility inside and outside with the ADM, reviewed documents, and interviewed staff members. During visit, LPA issued 2 Type B citations (refer to LIC809-D for details) and Civil Penalties for missing Caregiver Background checks (refer to LIC421BG for details).

Exit interview conducted. Copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/17/2023 03:28 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: ABRAHAM REST HOME
FACILITY NUMBER: 071440165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2023
Section Cited
CCR
87411(g)

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall

This requirement was not met as evidenced by:
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During inspection, Administrator provided proof of transfer for Ms. de la Cruz, Ms. Calderon vacated the facility, and proof of the initiation of fingerprinting process for Ms. Calderon was provided.
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Criminal record transfer for Claudia de la Cruz and initial DOJ certification for Dania Calderon had not been completed before working at the facility.
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Type B
05/24/2023
Section Cited
CCR87305(a)

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87208 PLAN OF OPERATION (a) Each facility shall have and maintain a current, written definitive plan of operation . . . on file in the facility . . . (7) Sketches, showing . . . (A) Building . . . uses intended and a designation of the rooms . . . for nonambulatory . . . and for bedridden residents . . . (B) The grounds showing buildings, driveways, fences . . . recreation area and other space used by the residents.
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On or before due date, Administrator shall send to LPA accurate and fully completed sketches in LIC999 and LIC200.
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This requirement was not met as evidenced by:

Inaccurate and/or missing sketches of the building and the yard.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2