079200406-5-31-2024-15-AS-AGOZ-D5SQ7G-20240531115507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200406
Report Date: 05/31/2024
Date Signed: 05/31/2024 11:55:31 AM

Document Has Been Signed on 05/31/2024 11:55 AM - 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:	EATON PLACE		FACILITY NUMBER:	079200406
ADMINISTRATOR:	ANABELLE GALERA		FACILITY TYPE:	740
ADDRESS:	20 EATON COURT		TELEPHONE:	(925) 837-8871
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	6	CENSUS: 5	DATE:	05/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator, Anabelle Galera		TIME COMPLETED:	12:15 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	On 5/31/2024 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Anabelle Galera and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory of which 2 may be bedridden. LPA toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 5 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in rooms 6 & 4 was measured at 106.3 & 107.3 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 and sharps were not locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 10/03/2023. Emergency Disaster Plan was last posted on 5/31/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 4/30/2024. At 9:00 AM, LPA reviewed 5 of 5 residents records. At 9:30 AM LPA reviewed 4 staff records and 4 of 4 have current first aid training and are associated to the facility. At 10:45AM, LPA reviewed a sample of resident’s medications. Report continues on LIC809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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 4

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: EATON PLACE	FACILITY NUMBER: 079200406
	VISIT DATE: 05/31/2024

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 DURING VISIT:

At 10:11am during tour LPA observed unlocked scissors in the kitchen cabinet. Robitussin, Gabapentin, Guaifenesin, and NyQuil were obserbed unsecured in refrigerator on right door shelf. Under kitchen sink was also unlocked with a variety of Knives, sharps, and cleaning supplies available. Staff locked away all items that posed a risk.

Updated copies of the following document were requested for facility file and are to be submitted to CCL by 6/21/2024:

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 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: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 05/31/2024 11:55 AM - 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: EATON PLACE	FACILITY NUMBER: 079200406
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: 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 sharps, medicines, and chemicals assessable which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Staff locked away all items that posed a risk.

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: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4