075601137-1-28-2025-15-AS-CFOR-DDCVT7-20250128154241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601137
Report Date: 01/28/2025
Date Signed: 01/28/2025 03:42:54 PM

Document Has Been Signed on 01/28/2025 03:42 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	PRIORITY CARE HOME I		FACILITY NUMBER:	075601137
ADMINISTRATOR/ DIRECTOR:	FERNANDEZ, AGNES		FACILITY TYPE:	740
ADDRESS:	985 CORAL RIDGE CIRCLE		TELEPHONE:	(510) 313-0411
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 1	DATE:	01/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	AGNES FERNANDEZ, ADMINISTRATOR		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 1/28/2025 at 1:30PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Agnes Fernandez, Administrator, and explained the purpose of the visit. The Administrator currently holds a certificate (#7004028740) that expires on 03/17/2026. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 70 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 87.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors was in operating condition during visit. Fire extinguisher was last serviced on 03/8/2024. Emergency Disaster Plan was posted. First aid kit was observed to be complete. LPA reviewed one (1) residents files and two (2) staff files which were all found to be complete. Continued on LIC809C.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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 01/28/2025 03:42 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PRIORITY CARE HOME I	FACILITY NUMBER: 075601137
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 having unlocked items such as laundry detergent, scissors, Clorox, Lysol, grip solvent located in the garage and in an unlocked cabinet in the garage which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/29/2025
	Plan of Correction
1 2 3 4	Administrator agreed to lock all items in a storage area and provide photo copies to CCLD by 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.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/28/2025 03:42 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PRIORITY CARE HOME I	FACILITY NUMBER: 075601137
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 the kitchen table and kitchen area full of clutter which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/04/2025
	Plan of Correction
1 2 3 4	Administrator agreed to clear and clean the clutter and provide photos to CCLD by the POC date.

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 the water temperature at 87.5 which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Administrator agreed to adjust the water temperature and submit a video showing the temperature to CCLD by the POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PRIORITY CARE HOME I	FACILITY NUMBER: 075601137
	VISIT DATE: 01/28/2025

NARRATIVE

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CONTINUE FROM LIC809

LPA observed the following deficiencies:

· At 1:50PM, LPA observed kitchen table and counters with clutter.
· At 1:57PM, LPA observed Lysol in the bathroom and a full trash can.
· At 1:59PM, LPA observed unlocked in the garage and a cabinet with laundry detergent, scissors, Clorox, Lysol, grip solvent
· At 2:05PM, LPA observed a rake fruit picker and generator unlocked located in the back yard.

LPA requested the following documents to be submitted to CCLD by 2/04/2025.

· 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

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. 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: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5

Document Has Been Signed on 01/28/2025 03:42 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PRIORITY CARE HOME I	FACILITY NUMBER: 075601137
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 a rake, fruit picker, and generator located in the back yard, which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/04/2025
	Plan of Correction
1 2 3 4	Administrator will remove rake, fruit picker, and generator from the backyard and will provide pictures to CCLD by 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.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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