079200977-4-2-2024-15-AS-CFOR-D3XSB9-20240402134334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200977
Report Date: 04/02/2024
Date Signed: 04/02/2024 01:43:51 PM

Document Has Been Signed on 04/02/2024 01:43 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:	WE CARE ELDERLY CARE		FACILITY NUMBER:	079200977
ADMINISTRATOR:	WHITE, BRITTANY D		FACILITY TYPE:	740
ADDRESS:	4155 BELL AVE		TELEPHONE:	(510) 375-4460
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY:	8	CENSUS: 7	DATE:	04/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	LURINZA BEAN, CAREGIVER/ ADMINISTRATOR		TIME COMPLETED:	02:05 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 4/2/2024 at 9:50am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Administrator/Caregiver Lurinza Bean, and explained the purpose of the visit. Administrator, Brittany White, arrived at 10:35am. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) bathrooms. LPA did not observe any bodies of water. A comfortable temperature is maintained at 68 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 114.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 03/03/2024. Emergency disaster plan last updated 5/24/2022. First aid kit was observed to be complete. Three (3) staff records were reviewed. LPA also reviewed five (5) resident records and they were current and complete. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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 5

Document Has Been Signed on 04/02/2024 01:43 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: WE CARE ELDERLY CARE	FACILITY NUMBER: 079200977
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 chemicals such as Ajax, Comet Awesome cleaner, Glade Carpet Cleaner, Fabuloso, WD-40, Lysol, Raid, 409, and a knife which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Administrator agreed to keep all chemicals such as Ajax, Comet Awesome cleaner, Glade Carpet Cleaner, Fabuloso, WD-40, Lysol, Raid, 409, and sharps locked at all times. Caregiver and Administrator locked all chemicals and knife during visit. DEFICIENCY CLEARED DURING VISIT.

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 04/02/2024 01:43 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: WE CARE ELDERLY CARE	FACILITY NUMBER: 079200977
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 5 piles of wood located in the backyard which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Administrator will have wood piles removed from the backyard and submit pictures to CCLD by POC date.

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: WE CARE ELDERLY CARE	FACILITY NUMBER: 079200977
	VISIT DATE: 04/02/2024

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

Continued from LIC809C.

Deficiencies LPA observed:

At 10:46am LPA Observed unlocked cabinets located in the hallway and kitchen which contained chemicals such as Ajax, Comet Awesome cleaner, Glade Carpet Cleaner, Fabuloso, WD-40, Lysol, Raid, 409, and a knife.

At 10:50am LPA Observed 5 piles of wood planks located in the back yard.

The following forms are to be updated and submitted to CCLD by 04/10/24:
-Resident Roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan

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 the appeal rights and this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5