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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200810
Report Date: 07/12/2024
Date Signed: 07/12/2024 01:28:40 PM


Document Has Been Signed on 07/12/2024 01:28 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:GEN CARE MANORFACILITY NUMBER:
079200810
ADMINISTRATOR:ARATAN, GENNY FIEFACILITY TYPE:
740
ADDRESS:5707 OSAGE PLACETELEPHONE:
(925) 889-9967
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:4CENSUS: 4DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Edgardo RosellonTIME COMPLETED:
01:50 PM
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On 07/12/2024 at 12:30 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Edgardo Rosellon and explained the purpose of the visit. The facility’s fire clearance was approved for 3 Non-Ambulatory and 1 Bedridden. Residents were away during the inspection

LPA toured facility with Administrator, Edgardo Rosellon including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which all 4 bedrooms are 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 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 117.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 09/01/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/01/2024.

At 12:35 PM, LPA reviewed 4 of 4 residents records. At 12:55 PM, LPA reviewed 4 staff records and 4 of 4 have first aid training and are associated to the facility. At 1:10 PM, LPA reviewed a sample of 4 of 4 resident’s medications.



No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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