075601236-7-10-2023-15-AS-PWAN-CTLQ33-20230710114804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601236
Report Date: 07/10/2023
Date Signed: 07/10/2023 11:48:17 AM

Document Has Been Signed on 07/10/2023 11:48 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	SEIKO'S PLACE		FACILITY NUMBER:	075601236
ADMINISTRATOR:	LINSZKY, SEIKO		FACILITY TYPE:	740
ADDRESS:	4967 HAMES DRIVE		TELEPHONE:	(925) 676-8963
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 4	DATE:	07/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Mateaki Ofahengaue, House Manager		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 07/10/2023 at 8:45 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with House Manager, Mateaki Ofahengaue and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPA toured facility with Mateaki including but not limited to bedrooms, bathroom, kitchen, common area and backyard. The facility consists of 5 total bedrooms which all 5 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 69 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 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 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 9/25/2022. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/03/2023. 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: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

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: SEIKO'S PLACE	FACILITY NUMBER: 075601236
	VISIT DATE: 07/10/2023

NARRATIVE

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At 9:25 AM, LPA reviewed 4 of 4 residents records. At 11:18 AM, LPA reviewed a sample of 4 of 4 resident’s medications.

The following deficiency was observed during inspection:
-At approximately 9:40 AM, LPA observed Resident 1 (R1), Resident 2 (R2) and Resident 4 (R4) resident records were incomplete. R1 binder was missing LIC 602A, LIC 625, LIC 601, Consent Forms and LIC 613. R2 binder was missing Consent forms, LIC 601 and LIC 613. R4 binder was missing LIC 625, LIC 601, Consent Forms and LIC 613.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/31/2023:

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

The following deficiencies were observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and 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) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/10/2023 11:48 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SEIKO'S PLACE	FACILITY NUMBER: 075601236
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not ensure that resident records are complete, R1, R2 and R4 have incomplete record files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2023
	Plan of Correction
1 2 3 4	Administrator will complete the missing forms for R1, R2 and R4, place them in the residents folders and provide proof of completion to CCL by 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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC809 (FAS) - (06/04)

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