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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601359
Report Date:
10/16/2024
Date Signed:
10/16/2024 01:07:13 PM
Document Has Been Signed on
10/16/2024 01:07 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:
HOME SWEET CARE HOMES
FACILITY NUMBER:
075601359
ADMINISTRATOR/
DIRECTOR:
SORIANO, CHRISTINE/CORNELL
FACILITY TYPE:
740
ADDRESS:
1584 DIANDA DRIVE
TELEPHONE:
(925) 689-2356
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94521
CAPACITY:
6
TOTAL ENROLLED CHILDREN:
0
CENSUS:
6
DATE:
10/16/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:
House Manager, Jet Siador
TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 10/16/2024 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with House Manager, Jet Siador and explained the purpose of the visit. LPA spoke with Administrator over the phone and they approved Jet to conduct the visit. The facility’s fire clearance was approved for 6 non-ambulatory and a hospice waiver for 2.
LPA toured facility with Jet including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which all 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 71 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 105.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication were locked and inaccessible to residents.
Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/13/2023. Emergency Disaster Plan was last posted on 10/16/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/01/2024.
At 10:50am, LPA reviewed 6 residents records. At 11:20 am, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility.
Report Continues on LIC809-C
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
Alona Gomez
TELEPHONE:
510-239-1306
DATE:
10/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2024
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
9
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:
HOME SWEET CARE HOMES
FACILITY NUMBER:
075601359
VISIT DATE:
10/16/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
At 9:40am LPA observed that Kitchen oven is broken and has a sign stating "DO NOT TOUCH BROKEN"*
At 9:42am LPA observed 2 knives, 2 scissors, and one lighter unlocked and accessible to residents in the kitchen in the drawer by the fridge*
At 9:43am LPA observed moldy bell peppers, slimy celery, and slimy broccoli in the refrigerator. Food was also improperly covered and stored in the refrigerator.*
At 9:53am LPA observed a roll away bed in the common area living room. LPA asked who uses the bed and if anyone sleeps in the living room to which the House Manager replied that Night Staff use it and also sometimes sleep on the couch. LPA also observed staffs personal toiletries on side of the couch.*
At 9:58am LPA observed that room 4 had oxygen but that the required oxygen in use sign was not posted.*
At 9:59am LPA observed that the walkway to access the sink was blocked in room 5 by mattress and hoyer lift.*
At 10:00am LPA observed that the shower did not have a non-slip mat. Later LPA observed that the other shower also did not have a mat but rather a wet bath towel on the floor.*
At 10:01am LPA observed that the tile in front of room 5's shower is cracked and able to lift up. The baseboards were also observed with water damage*
At 10:04am and throughout visit LPA observed a thick coating of dust and cobwebs on air vents, fans, behind refrigerator and in corners of walls by the ceiling and by floor area*
At 10:08am LPA observed a rat trap in room 1. when LPA went to look for signs of vermin they found under the kitchen sink rat feces, and a dead mouse.*
At 10:11am LPA observed a broken/ cracked outlet cover in room 3. Also a hole in the wall behind bedroom door measuring about 4 inches. The kitchen also had a similar hole, peeling paint, and rips in dining chairs.*
At 10:25am LPA observed a pile of boxes blocking the walkway, as well as mattresses and other items improperly stored outside.*
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-Larios
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2024
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
10/16/2024 01:07 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:
HOME SWEET CARE HOMES
FACILITY NUMBER:
075601359
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in having mice in the kitchen which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date:
11/07/2024
Plan of Correction
1
2
3
4
By POC date Administrator agrees to update the department with the status of the extermination services.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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 in having knives and scissors accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/16/2024
Plan of Correction
1
2
3
4
Staff locked away dangerous items
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) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
10/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2024
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
10/16/2024 01:07 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:
HOME SWEET CARE HOMES
FACILITY NUMBER:
075601359
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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 in there being layers of dust, cobwebs, broken flooring, and damaged baseboards which poses a potential health,and personal rights risk to persons in care.
POC Due Date:
11/07/2024
Plan of Correction
1
2
3
4
By POC date Administratr agrees to sanatize, clean, and repair facility, and notify CCLD.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
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 in 2 out of 2 bathrooms not having non-skid mats which poses a potential safety risk to persons in care.
POC Due Date:
11/07/2024
Plan of Correction
1
2
3
4
By POC date Administrator agrees to put mats in all showers and notify CCLD.
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) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
10/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2024
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
10/16/2024 01:07 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:
HOME SWEET CARE HOMES
FACILITY NUMBER:
075601359
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on observation the licensee did not comply with the section cited above in blocking indoor and outdoor walkways which poses a potential safety rights risk to persons in care.
POC Due Date:
11/07/2024
Plan of Correction
1
2
3
4
By POC date Administrator agrees to clear all walkways and notify CCLD.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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 in having spoiled produce and some food not properly covered which poses a potential health rights risk to persons in care.
POC Due Date:
10/16/2024
Plan of Correction
1
2
3
4
Spoiled food was thrown away and facility still had sufficient food.
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) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
10/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2024
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
10/16/2024 01:07 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:
HOME SWEET CARE HOMES
FACILITY NUMBER:
075601359
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.
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 in the kitchen oven being broken which poses a potential personal rights risk to persons in care.
POC Due Date:
11/07/2024
Plan of Correction
1
2
3
4
By POC date Administrator agrees to replace the oven and notify CCLD.
Type B
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 in not having the oxygen in use posted which posed a potential safety risk to persons in care.
POC Due Date:
10/16/2024
Plan of Correction
1
2
3
4
Staff posted the correct signs.
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) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
10/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2024
LIC809
(FAS) - (06/04)
Page:
6
of
9
Document Has Been Signed on
10/16/2024 01:07 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:
HOME SWEET CARE HOMES
FACILITY NUMBER:
075601359
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
87307 (a)Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in allowing staff to sleep in the living room at night which poses a potential personal rights risk to persons in care.
POC Due Date:
11/07/2024
Plan of Correction
1
2
3
4
By POC Administrator agrees to have all staff belongings removed and no longer allow staff to sleep at the facility effective immediately and notify CCLD.
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) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
10/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2024
LIC809
(FAS) - (06/04)
Page:
9
of
9