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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601236
Report Date: 07/12/2024
Date Signed: 07/12/2024 03:43:08 PM


Document Has Been Signed on 07/12/2024 03:43 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:SEIKO'S PLACEFACILITY NUMBER:
075601236
ADMINISTRATOR:LINSZKY, SEIKOFACILITY TYPE:
740
ADDRESS:4967 HAMES DRIVETELEPHONE:
(925) 676-8963
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Caregiver, Gladys CorpuzTIME COMPLETED:
04:00 PM
NARRATIVE
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On 07/12/2024 at 1:50 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Caregiver, Gladys Corpuz and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory.

LPA toured facility with caregiver 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 77 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 serviced on 10/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 05/01/2024.

At 9:25 AM, LPA reviewed 4 of 4 residents records. All resident files were incomplete and missing required documents. At 11:18 AM, LPA reviewed a sample of 4 of 4 resident’s medications.

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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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 07/12/2024 03:43 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SEIKO'S PLACE
FACILITY NUMBER: 075601236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 residents which poses a potential personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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By POC administrator agrees to review and update the resident files and notify CCLD
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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