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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601355
Report Date:
08/16/2023
Date Signed:
08/16/2023 03:34:31 PM
Document Has Been Signed on
08/16/2023 03:34 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:
APPLE GARDENS HOME
FACILITY NUMBER:
075601355
ADMINISTRATOR:
MARABLE, ANGELITO I.
FACILITY TYPE:
740
ADDRESS:
1611 APPLE DRIVE
TELEPHONE:
(925) 676-9627
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94518
CAPACITY:
6
CENSUS:
3
DATE:
08/16/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:40 PM
MET WITH:
Angelito Marable, Licensee
TIME COMPLETED:
03:45 PM
NARRATIVE
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On 08/16/2023 at 12:40 pm Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Licensee, Angelito Marable and explained the purpose of the visit.
LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer.
At 1:02 pm LPA reviewed 3 residents records. At 1:45 pm, LPA reviewed 2 staff records and 2 of 2 were fingerprint cleared and associated to the facility.
The following deficiency was observed during the visit:
The facility does not have a copy of their current liability insurance
Chemicals were observed unlocked in laundry room
A chair was blocking the exit to the backyard
The facility does not have enough staff
Medications were observed unlocked
Continued on LIC-809C...
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
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
6
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:
APPLE GARDENS HOME
FACILITY NUMBER:
075601355
VISIT DATE:
08/16/2023
NARRATIVE
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...Continued from LIC 809
There is no "No smoking - Oxygen in use" sign posted
There are bed rails on all residents beds in-use only one of the three have doctors orders
The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
6
of
6
Document Has Been Signed on
08/16/2023 03:34 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:
APPLE GARDENS HOME
FACILITY NUMBER:
075601355
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not having their current copy of the liability insurence at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2023
Plan of Correction
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2
3
4
The facility agrees to send in a copy of the liability insurence to CCLD. Proof of correction will be sent in to CCLD by POC date.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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 a recliner chair blocking the backyard passageway which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2023
Plan of Correction
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The facility agrees to remove the chair from blocking the outside passageway and dispose of it. Proof of correction will be sent in 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
08/16/2023 03:34 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:
APPLE GARDENS HOME
FACILITY NUMBER:
075601355
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/16/2023
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having the laundry soap unlocked in the laundry room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2023
Plan of Correction
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2
3
4
The facility agrees to lock the cabinet the laundry soap is in and lock the laundry room door. Proof of correction will be sent to CCLD by POC date.
Type A
Section Cited
HSC
1569.618(c)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interviews, and record review, the licensee did not comply with the section cited above by having only two staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2023
Plan of Correction
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4
The facility agrees to hire more staff for the facility, and send in an updated LIC 500. Proof of correction will be sent in 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
08/16/2023 03:34 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:
APPLE GARDENS HOME
FACILITY NUMBER:
075601355
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above by having all three medication drawers unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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4
The facility agrees to lock up the medications and to review the regulations regarding medication storage. Proof of correction will be sent in to CCLD by POC date.
Type A
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by having bed rails on two residents beds without doctors orders, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2023
Plan of Correction
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2
3
4
The facility agrees to remove the bed rails from the beds and will obtaine the doctors orders for the residents files before they are put back on. Proof of correction will be sent in 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
08/16/2023 03:34 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:
APPLE GARDENS HOME
FACILITY NUMBER:
075601355
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.
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 resident with a perscription of Oxygen not having a sign posted saying “No Smoking-Oxygen in Use” which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/25/2023
Plan of Correction
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2
3
4
The facility agrees to post a sign say “No Smoking-Oxygen in Use” on the door of the residents room. Proof of correction will be sent in to CCLD 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
5
of
6