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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075600294
Report Date:
08/21/2023
Date Signed:
08/21/2023 05:42:18 PM
Document Has Been Signed on
08/21/2023 05:42 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:
ABRAHAM REST HOME
FACILITY NUMBER:
075600294
ADMINISTRATOR:
SANCHEZ, ALEX
FACILITY TYPE:
740
ADDRESS:
1095 BANCROFT COURT
TELEPHONE:
(925) 945-7398
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94598
CAPACITY:
6
CENSUS:
5
DATE:
08/21/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:30 AM
MET WITH:
Annette Sanchez
TIME COMPLETED:
06:00 PM
NARRATIVE
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On 08/21/2023 at 10:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility for Required Annual Inspection. Upon arrival, LPA stated purpose of the inspection to Administrator (ADM) Annette Sanchez.
LPA toured facility inside and outside. Facility is clean and safe and well maintained.
LPA reviewed files of 5 residents and 5 staff members and found them to be incomplete. LPA interviewed 2 staff and 2 residents, and found the staff to be fully competent and the residents to be well cared for.
2 A-Type and 4 B-Type citations issued during the inspection (refer to LIC809-D for details).
Follow-up from Licensee requested:
Send proof of liability insurance to LPA by 08/28/2023.
Exit interview conducted with ADM. A copy of this report provided for ADM by LPA via email.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/21/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/21/2023
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
4
Document Has Been Signed on
08/21/2023 05:42 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:
ABRAHAM REST HOME
FACILITY NUMBER:
075600294
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the facility where the door to the garage where cleaning solutions are stored unlocked was not locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/22/2023
Plan of Correction
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2
3
4
Corrected during inspection
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the centrally stored medication cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/22/2023
Plan of Correction
1
2
3
4
Corrected during inspection
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:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/21/2023
LIC809
(FAS) - (06/04)
Page:
2
of
4
Document Has Been Signed on
08/21/2023 05:42 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:
ABRAHAM REST HOME
FACILITY NUMBER:
075600294
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in the garage, where the restroom for room #7 is built into the garage, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/25/2023
Plan of Correction
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2
3
4
Licensee shall verify whether a permit exists for that bathroom or not. If not, they shall create a written plan on what to do about it based on consultation with the City of Walnut Creek Planning Department. If it cannot be licensed by the City, then it shall be removed and the garage shall be returned to its original use as a garage only.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
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 all staff members, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/28/2023
Plan of Correction
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2
3
4
All staff members shall complete their first aid and CPR training (as required by their position).
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:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/21/2023
LIC809
(FAS) - (06/04)
Page:
3
of
4
Document Has Been Signed on
08/21/2023 05:42 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:
ABRAHAM REST HOME
FACILITY NUMBER:
075600294
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87415(a)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:
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 ensuring that all night personnel were training in CPR as well as first aid, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/28/2023
Plan of Correction
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3
4
All night supervision staff members shall complete their first aid and CPR training.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
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 all of the staff members' dementia training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/28/2023
Plan of Correction
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2
3
4
All staff members shall complete the 8 hours of annual dementia training.
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:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/21/2023
LIC809
(FAS) - (06/04)
Page:
4
of
4