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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601472
Report Date: 11/03/2023
Date Signed: 11/03/2023 05:08:21 PM


Document Has Been Signed on 11/03/2023 05:08 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:WELCOME HOME SENIOR RESIDENCE (ALAMO II)FACILITY NUMBER:
075601472
ADMINISTRATOR:CHOU, SETEVE & GALLO, CFACILITY TYPE:
740
ADDRESS:10 CASTLE CREST ROADTELEPHONE:
(510) 685-8388
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Engracia De Jesus, CaregiverTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) A. Gomez and L. Hall arrived unannounced to conduct 1-Year Annual Required visit on this date starting at 1:20pm. Upon arrival, LPA met with Caregiver Engracia De Jesus and explained the reason of the visit. Administrator unavailable. The facility's fire clearance was approved for six non-ambulatory.

LPA toured facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six (5) total bedrooms which all 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 70 degrees Fahrenheit. LPAs 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 107.6 degrees F. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps are locked and inaccessible to residents.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/01/2021. Emergency Disaster Plan is posted. First aid kit was observed to be complete. Fire drill was last conducted on 12/30/2023.

LPA reviewed 4 staff records and 3 of 4 staff have current first aid training and associated to the facility. LPA reviewed 4 residents records and 4 of 4 residents have current medical assessment.

Report continues on 809C

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WELCOME HOME SENIOR RESIDENCE (ALAMO II)
FACILITY NUMBER: 075601472
VISIT DATE: 11/03/2023
NARRATIVE
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The following deficiencies were observed:
  • At 1:50pm during staff file review LPA's observed 1 (S4) missing physicians reports and TB test
  • At 2:00pm LPA's observed fire extinguisher to have been last serviced 12/01/2021
  • At 3:00pm LPA's observed bedridden resident placed in room 2. Room 5 is only room cleared for bedridden
  • At 3:20pm LPA's observed that there is no current administrator certificate on file

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 11/20/2023:

· 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

. Updated Facility Sketch

*An immediate civil penalty of $500.00 will be assessed on today's date for a fire clearance violation*

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with Caregiver. A copy of this report, LIC421M and appeal rights provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 11/03/2023 05:08 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: WELCOME HOME SENIOR RESIDENCE (ALAMO II)
FACILITY NUMBER: 075601472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearence 87202 (a)All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above by having a bedridden resident in an unapproved room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2023
Plan of Correction
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By POC date licensee agrees to submit a plan to move bedridden residents to fire clearence approved room to CCLD
Section Cited
Deficient Practice Statement
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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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 11/03/2023 05:08 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: WELCOME HOME SENIOR RESIDENCE (ALAMO II)
FACILITY NUMBER: 075601472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87405(a)
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.


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 fire extinguisher that is not up to date on being serviced which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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By POC date licensee agrees to have fire extinguisher serviced and submit photographic proof to CCLD
Request Denied
Type B
Section Cited
CCR
87405(a)
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited aboveby having an expired administrator certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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By POC date Licensee agrees to submit all documents required to add a new administrator to 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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 11/03/2023 05:08 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: WELCOME HOME SENIOR RESIDENCE (ALAMO II)
FACILITY NUMBER: 075601472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 by caretaker not having a TB test on record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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By POC date licensee agrees to submit a copy of S4's TB test to 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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5