075601041-3-12-2024-15-AS-AGOZ-D3APXB-20240312114204

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601041
Report Date: 03/12/2024
Date Signed: 03/12/2024 11:42:13 AM

Document Has Been Signed on 03/12/2024 11:42 AM - 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:	GINES RESIDENTIAL CARE HOME III		FACILITY NUMBER:	075601041
ADMINISTRATOR:	GINES, ERLINDA		FACILITY TYPE:	740
ADDRESS:	2565 STONE VALLEY ROAD		TELEPHONE:	(925) 743-1146
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	6	CENSUS: 4	DATE:	03/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Erlinda Gines		TIME COMPLETED:	12:00 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 3/12/2024 at 10:00AM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit and met with Administrator, Erlinda Gines . The facility is cleared for all may be non-ambulatory. LPA toured and inspected the facility inside and outside with administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which four (4) bedrooms are currently occupied by the residents and one (1) bedroom is occupied by staff. The facility has auditory signals on each sliding door in the resident's room. All outdoor and indoor passageways are kept free of obstruction. There were no bodies of water present at this facility. LPA observed medication located in Kitchen and were observed to be locked. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. A comfortable temperature is maintained at 70 degrees Fahrenheit. Hot water temperature in the residents’ shared bathroom was measured at 113.3 degrees F. Resident's bathrooms have grab bars inside the shower. The showers have non-skid mat. Hygiene items, extra linens and toiletry supplies were checked and sufficient. Fire extinguisher in kitchen was last serviced on 4/18/2023, smoke detectors and carbon monoxide were operational. First aid kit was inspected and was complete. Food supplies were sufficient to meet 2-day perishable and 7-day non-perishable requirements. 4 of 4 Resident records were reviewed at approximately 10:15AM. 3 of 3 Staff records were reviewed at approximately 10:36 AM. All staff were fingerprinted and associated to the facility. All staff have current CPR First aid certifications. First Aid kit was observed complete. Emergency disaster plan last reviewed 3/11/2024. report continues on 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: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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 3

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: GINES RESIDENTIAL CARE HOME III	FACILITY NUMBER: 075601041
	VISIT DATE: 03/12/2024

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
26
27
28
29
30
31
32

The Following Deficiencies were Observed

At 10:50 during file review LPA observed and found out through conversation with administrator that there is not adequate staffing for the needs of residents as R4 can require a 2 person assist

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 03/31/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610E Emergency Disaster Plan

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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/12/2024 11:42 AM - 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: GINES RESIDENTIAL CARE HOME III	FACILITY NUMBER: 075601041
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(a)

Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in not having enough staff scheduled for a 2 person assist which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Durring visit Administrator called in more staff.

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: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3