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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601490
Report Date: 10/12/2023
Date Signed: 10/12/2023 07:57:16 PM


Document Has Been Signed on 10/12/2023 07:57 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MAUREEN HOUSEFACILITY NUMBER:
075601490
ADMINISTRATOR:JOSE MICHAEL TORIOFACILITY TYPE:
740
ADDRESS:590 MAUREEN LANETELEPHONE:
(925) 818-6536
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 6DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Jose Michael Torio, AdministratorTIME COMPLETED:
08:30 PM
NARRATIVE
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On 11:25AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiv er, Marita Sablay the purpose of the visit. Jose Michael Torio arrived approx. 30mins later. Jose's Administrator Certificate# 6033028740 Expires 10/22/24. The facility’s fire clearance was approved for 6 residents Non-Ambulatory and 1 Bedridden in Rm# 6 only.

LPA toured facility with Jose including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. A comfortable temperature is maintained at 70 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 108.3, 109, 109.5 degrees Fahrenheit. 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 were locked and inaccessible to residents.

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 04/04/2023. Emergency Disaster Plan was last posted in 2019. First aid kit was observed to be complete. Emergency disaster drill was last conducted on .

At 12:17PM, LPA reviewed 6 residents records. At 3:13PM, LPA reviewed 7 staff records and 6 of 7 have current first aid training and associated to the facility.

LIC809C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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: MAUREEN HOUSE
FACILITY NUMBER: 075601490
VISIT DATE: 10/12/2023
NARRATIVE
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LIC809 Continued....

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 11:40 AM LPA observed scissors unlocked underneath sink cabinet
At 12:10 PM LPA observed washing machine, boxes on outside garage
At 12:11 PM LPA observed empty laundry detergent buckets behind shed
At 12:12 PM LPA observed pot, spoon, green screen door, wood, debris behind outside shed

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 Penaltieties



Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/19/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Updated facility sketch


Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2023 07:57 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: MAUREEN HOUSE
FACILITY NUMBER: 075601490

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, the licensee did not comply with the section cited above in not having scissors locked which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Scissors were removed during visit. Deficiency cleared.
Type A
Section Cited
CCR
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.

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 in not having R4 in a Bedridden room which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Licensee/Administrator says that there's a discrepancy and that the Bedridden room is actually Room# 5 and not #6. Licensee/Administrator says that he will contact the fire department to try to clear the descrepancy with the rooms. Licensee/Administrator will submit to CCLD the facility sketch and LIC200 to request Bedridden for Rm# 5 if it's not corrected by the Fire Marshall by POC due 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8


Document Has Been Signed on 10/12/2023 07:57 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: MAUREEN HOUSE
FACILITY NUMBER: 075601490

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in having Quarterly FIre Drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Administrator will review the regulation, self-certify that they read and understand the regulation and send a copy of a current fire drill to CCLD by POC due date.
Type B
Section Cited
CCR
87705(c)(2)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (2) The Emergency Disaster Plan, as required in Section 87212, addresses the safety of residents with dementia.

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 in not having an Emergency Disaster Drill thats is reviewed and current which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Administrator will review the regulation, self-certify that they read and understand the regulation and send a copy of a current Emergency Disaster Drill (LIC610E) to CCLD by POC due 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 10/12/2023 07:57 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: MAUREEN HOUSE
FACILITY NUMBER: 075601490

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633
Hospice Care of Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

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 having hospice care plan available for R1 and R6 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Administrator found the hospice care plan for R1 and R6 later during visit, Deficiency cleared.
Type B
Section Cited
CCR
87609
Allowable Health Conditions and the Use of Home Health Agencies
(c) (c) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met:

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 in having doctor's orders for private Physical Therapist for R3, R4, R5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Administrator will read the regulation and self-certify that they read and understand the regulations. Administrator will send doctor's orders for private Physical Therapists. Admnistrator will update care palns for each resident that has the private Physical Therapist or any other private medical/health services and send to CCLD by POC due 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 10/12/2023 07:57 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: MAUREEN HOUSE
FACILITY NUMBER: 075601490

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person....

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 in having an availble Administrator during Annual visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Administrator will send to CCLD an updated LIC500 that shows the Administrator days and hours working at the facility to CCLD by POC due date.
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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8


Document Has Been Signed on 10/12/2023 07:57 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: MAUREEN HOUSE
FACILITY NUMBER: 075601490

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87615
87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above for retaining R5 without submitting an exception request for prohibited health condition which poses a potential health and safety risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Licensee/Administrator will read the regulation and self-certify that they understand moving forward. Licensee/Administartor stated that he is going to submit an exception request with supporting documents to CCLD by POC Due Date. Deficiency will not be cleared until exception request is approved.
Type B
Section Cited
CCR
87303
(a) 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

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 in having washing machine, boxes, screen doors, pots/spoons, debris removed from outside yards which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Administrator will remove items, clean yard and send photos to CCLD by POC due 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8