075601503-2-22-2024-15-AS-AGOZ-D2PSUA-20240222131048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601503
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:11:00 PM

Document Has Been Signed on 02/22/2024 01:11 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:	MAGNOLIA GARDEN AT DANVILLE		FACILITY NUMBER:	075601503
ADMINISTRATOR:	OLIVA, JOSEPH ANTHONY		FACILITY TYPE:	740
ADDRESS:	205 EL PINTO ROAD		TELEPHONE:	(925) 820-9801
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	36	CENSUS: 17	DATE:	02/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Heidi Yrreverre		TIME COMPLETED:	01:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct an Annual Inspection starting at 9:00AM. During the inspection, LPA met with Administrator, Heidi Yrreverre. LPA toured the facility inside and out with including but not limited to random resident’s apartments, kitchen, dining area, common area, and courtyard. The Administrator currently holds a certificate (#6047315740) that expires on 4/30/2024. The facility’s fire clearance was approved for 36 residents, all of whom may be non-ambulatory. 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. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in Resident 4's bathroom was measured at 122.5 degrees Fahrenheit and the hot water temperature in Residents 5's bathroom measured at 121 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower floor pan. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Freezer temperature measured at -5 degrees Fahrenheit and fridge measured at 38 degrees Fahrenheit. LPA observed interconnected smoke detectors and sprinklers. Carbon monoxide was in working condition during visit. Fire extinguisher was last serviced on 4/14/2023. First aid kit was observed to be complete. Fire and Earthquake Drill drill was last conducted on 1/23/2023. Emergency disaster plan last reviewed 2/22/2024. LPA reviewed 5 staff record files and 5 of 5 staff have criminal record clearance and are associated to the facility. LPA reviewed 5 residents’ files and a sample of the medication. Report Continues on LIC 809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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 6

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: MAGNOLIA GARDEN AT DANVILLE	FACILITY NUMBER: 075601503
	VISIT DATE: 02/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The following deficiencies were observed:

At 9:30AM during file review LPA observed resident files to be incomplete. R1 is missing emergency consent. R2 is missing appraisal of needs and services. R4 is missing personal rights, updated physicians report, and emergency medical consent. R5 is missing an updated appraisal of needs and services.
At 10:00AM during file review LPA observed that last disaster drill was done 1/23/2023
At 10:30AM during file review S3's file was observed having a CPR/First aid certificate that expired 1/19/2020. Administrator then produced a certificate that expires 2/22/2026. Administrator did inform LPA that when they heard that the annual inspection was being done they told S3 to complete and update their certificate during the visit. LPA informed administrator that all certificates and documents are to be complete before visit and not done as a result of inspection.
At 11:15AM during facility tour LPA observed the hot water temperature in R4's bathroom at 122.5 degrees Fahrenheit and in R5's bathroom 121 degrees Fahrenheit.

****A civil penalty of $250 x 2 is being assessed today for repeat violations in a 12 month period****

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 3/1/2024

LIC 500 Personnel Report

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. LIC421F, 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: 02/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 02/22/2024 01:11 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: MAGNOLIA GARDEN AT DANVILLE	FACILITY NUMBER: 075601503
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 residents bathrooms hot water temprature being above 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	By POC date Administrator agrees to adjust water to within range and self certify to 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: 02/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 02/22/2024 01:11 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: MAGNOLIA GARDEN AT DANVILLE	FACILITY NUMBER: 075601503
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in S3 not being first aid certified which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	Administrator had S3 update first aid certificate during visit. Deficiency cleared.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in residents files being incomplete which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to review all client records and update them and self certify 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-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 02/22/2024 01:11 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: MAGNOLIA GARDEN AT DANVILLE	FACILITY NUMBER: 075601503
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not doing a quarterly drill which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	By POC date Administrator agrees to complete and log required drills and self certify to 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: 02/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6