<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200822
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:34:20 PM


Document Has Been Signed on 09/29/2022 04:34 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:HOME SWEET HOME OF HERCULESFACILITY NUMBER:
079200822
ADMINISTRATOR:DASTGHEIB, ALI SINAFACILITY TYPE:
740
ADDRESS:295 SPARROW DRTELEPHONE:
(510) 245-2948
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 5DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Raymond Supan, CaregiverTIME COMPLETED:
04:53 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 09/29/2022 at 2:50 PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Raymond Supan and explained the purpose of the visit.

Upon entry, LPA temperature was checked by staff. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitors log and temperature logs for residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPAs observed PPE and paper supplies are sufficient.

The following deficiencies observed during the visit:

-At 3:00 pm, LPA observed round up weed killer, weed eater, rake, slug & snail killer, and paint, located in an unlocked garage.
-At 3:07 pm LPA observed a knife and syringe an unlocked drawer located in the kitchen.
-At 3:09 pm, LPA observed gardening soil located in the backyard.
-At 3:11 pm LPA observed a building for dwelling located in the backyard.


The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.,
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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 2


Document Has Been Signed on 09/29/2022 04:34 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: HOME SWEET HOME OF HERCULES
FACILITY NUMBER: 079200822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
87705(f)(1) Knives, tools, firearms

(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
1
2
3
4
Based on LPA observation licensee did not comply with the section cited above by having a weed eater, round up week killer, rake, slug & snail killer, bleach, air freshener, lysol, gardening soil and comet which poses an immediate health and safety risk to residents in care.
POC Due Date: 10/06/2022
Plan of Correction
1
2
3
4
Administrator agreed to flip the top lock on the door leading to the garage to make garage inaccessible to residents in care.
Deficiency cleared during visit.
Type B
Section Cited
CCR
87202(a)
87202 (a) Fire Clearance

87202 Fire Clearance (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
1
2
3
4
Based on observation and records review, Licensee failed to have storage shed in back yard cleared as a living space which poses an immediate health and safety risk to residents in care.
POC Due Date: 10/13/2022
Plan of Correction
1
2
3
4
Administrator agreed to vacate the storage shed and submit a LIC 200 along with an updated facility sketch to request for a new fire clearance to CCLD no later then the POC 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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2