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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601137
Report Date: 03/06/2024
Date Signed: 03/06/2024 02:24:32 PM


Document Has Been Signed on 03/06/2024 02:24 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 IFACILITY NUMBER:
075601137
ADMINISTRATOR:FERNANDEZ, AGNESFACILITY TYPE:
740
ADDRESS:985 CORAL RIDGE CIRCLETELEPHONE:
(510) 313-0411
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY:6CENSUS: 3DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:AGNES FERNANDEZ, ADMINISTRATORTIME COMPLETED:
02:40 PM
NARRATIVE
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On 3/6/2024 at 10:40AM, 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 (#6014213740) that expires on 03/16/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility with Caregiver 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 74 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 101.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors was in operating condition during visit. Fire extinguisher was last serviced on 06/24/2019. Emergency Disaster Plan was posted. First aid kit was observed to be complete.

LPA reviewed three (3) residents files and three (3) staff files which were all found to be complete.

Continued on LIC809C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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 5


Document Has Been Signed on 03/06/2024 02:24 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: 03/06/2024

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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Based on observation, the licensee did not comply with the section cited above by having 2 cans of Lysol spray located in the living room drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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Administrator agreed to keep Lysol locked at all times. DEFICIENCY CLEARED DURING VISIT.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


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: 03/06/2024
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CONTINUE FROM LIC809

LPA observed the following deficiencies:

· At 11:00AM, LPA observed 2 cans of Lysol spray in the living room.
· At 11:45AM, LPA observed home defense spray, ladder, 2 shovels, rake, push mower, unlocked shed and moss on walkway located in the backyard.
· At 11:55AM, LPA observed fire extinguisher last serviced/purchased 6/24/2019
· At 12:00PM, LPA observed living quarters (bed with covers, office space, clothing in cabinet, medication) located in the garage.
  • At 2:00PM LPA observed facility is missing a carbon monoxide detector.

LPA requested the following documents to be submitted to CCLD by 3/13/2024.

· 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.

*An immediate $500.00 civil penalty will be assessed on today's date for associations.*

Exit interview conducted. A copy of the LIC421BG, this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 03/06/2024 02:24 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: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(A)
Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation licensee did not comply with the section cited above by staff sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents.
POC Due Date: 03/20/2024
Plan of Correction
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Administrator agreed not to allow staff/son to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCL by POC date.
Civil penalty of $500 is being assessed for fire clearance violation.
Type B
Section Cited
CCR
87203
Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. In accordance with the 2013 California Fire Code 906.1, the Licensee shall obtain and store at least one 2A:10B:C rated fire extinguisher that has been mounted in a visible and accessible location with the top of the extinguisher no higher than 5 feet. The maximum travel distance to an extinguisher shall not be more than 75 feet. Fire extinguishers shall be serviced annually with a service tag attached.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, the licensee did not comply with the section cited above. The fire extinguisher was last serviced on 3/16/2024, which poses a potential health and safety risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Administrator will ensure fire extinguisher is serviced and submit proof of serviced extinguisher tag to CCL by 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/06/2024 02:24 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: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation, the licensee did not comply with the section cited above by having home defense chemical, ladder, 2 shovels, rake, push mower, moss on walkway and unlocked shed located in the backyard, which poses a potential health and safety or personal risk to persons in care.
POC Due Date: 03/20/2024
Plan of Correction
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Administrator agreed to lock the home defense chemical, ladder, 2 shovels, rake, push mower and have the moss cleaned off the walkway, lock the shed and provide pictures to CCL by the POC date.
Type B
Section Cited
HSC
1569.311
Carbon monoxide detectors required; inspection. Every residential care facility for the elderly shall have one or more carbon monoxide detectors...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above by not have carbon monoxide detectors in the facility which poses a potential health and safety risk to the residents in care.
POC Due Date: 03/13/2024
Plan of Correction
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Administrator will install carbon monoxide detectors in common areas of the facility. Administrator will submit purchase receipts and pictures of the carbon monoxide detector to CCLD by 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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