079200574-3-26-2024-15-AS-CFOR-D3QVNE-20240326163502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200574
Report Date: 03/26/2024
Date Signed: 03/26/2024 04:35:09 PM

Document Has Been Signed on 03/26/2024 04:35 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	ABSOLUTE CARE FOR LIFE		FACILITY NUMBER:	079200574
ADMINISTRATOR:	LEVIN, EMCY MADRIAGA		FACILITY TYPE:	740
ADDRESS:	1700 MARLESTA ROAD		TELEPHONE:	(510) 478-8926
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	6	CENSUS: 5	DATE:	03/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:27 PM
MET WITH:	GLORYCIEL CAVANTING, CAREGIVER		TIME COMPLETED:	05:00 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 3/26/2024 at 1:27pm, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Gloryciel Cavanting Caregiver, and explained the purpose of the visit. Emcy Levin, Administrator arrived at 1:50pm. The Administrator currently holds a certificate (#6013527740) that expired on 03/15/2024 and is waiting on her renewal. The facility’s fire clearance was approved for three (3) ambulatory and three (3) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms and three (3) bathrooms. 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 the residents’ shared bathroom was measured at 109.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/27/2023. Emergency Disaster Plan was posted. First aid kit was observed to be complete. Earthquake and fire drill last conducted on 3/1/2024. LPA reviewed four (4) resident files and three (3) staff files all complete. CONTINUE ON LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ABSOLUTE CARE FOR LIFE	FACILITY NUMBER: 079200574
	VISIT DATE: 03/26/2024

NARRATIVE

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CONTINUE FROM LIC809

LPA observed the following deficiencies:

· At 1:55pm, LPA observed living quarters in the garage.
· At 2:05pm, LPA observed 8 tires, wood planks located in the backyard.

LPA requested the following documents to be submitted to CCLD by 4/04/2024.

· 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

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/26/2024 04:35 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ABSOLUTE CARE FOR LIFE	FACILITY NUMBER: 079200574
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(B)

(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: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on, the licensee did not comply with the section cited above by using a room in the garage for staff sleeping which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove bed, clothing and shoes, dressers and use for breakroom/storage which room has been fire cleared for. Administrator will provide photos of room once cleared.

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 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 by having 8 tires and wood planks located in the back yard which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have items listed removed from the backyard no later than the POC date. DEFICIENCY CLEARED DURING VISIT.

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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

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