075600354-9-29-2023-15-AS-PWAN-CW5T7T-20230929142917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600354
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:29:22 PM

Document Has Been Signed on 09/29/2023 02:29 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:	PENNY'S GUEST HOME		FACILITY NUMBER:	075600354
ADMINISTRATOR:	EPIFANIA ANGECIA		FACILITY TYPE:	740
ADDRESS:	1760 AYERS ROAD		TELEPHONE:	(925) 330-3086
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 6	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Josefina Gardner, Licensee		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 09/29/2023 at 12:15 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by caregivers. Licensee arrived at 12:37 PM. LPA met with Licensee, Josefina Gardner and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPA toured facility with Josefina including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedroom are 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 75 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 and personal bathrooms was measured within range of 105-120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last purchased on 09/20/2022, Licensee stated they will purchase a new extinguisher and provide proof of purchase. First aid kit was observed to be complete. Fire drill was last conducted on 08/17/2023. Report continues on 809 C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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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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: PENNY'S GUEST HOME	FACILITY NUMBER: 075600354
	VISIT DATE: 09/29/2023

NARRATIVE

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At 12:40 PM, LPA reviewed 6 of 6 residents records. At 1:20 PM, LPA reviewed 8 of 8 staff records and 8 of 8 have first aid training and associated to the facility. At 1:52 PM, LPA reviewed a sample of 6 of 6 resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/13/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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