079200997-11-2-2023-15-AS-LHAL-CX7TF2-20231102144048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200997
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:40:56 PM

Document Has Been Signed on 11/02/2023 02:40 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:	FAM CARE HOMES, LLC		FACILITY NUMBER:	079200997
ADMINISTRATOR:	OKPARA, CHIOMA ABIGAIL		FACILITY TYPE:	740
ADDRESS:	1502 PEPPERTREE PLACE		TELEPHONE:	(925) 481-4397
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY:	6	CENSUS: 4	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Chioma "Abigail" Okpara, Administrator		TIME COMPLETED:	02:50 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 11/2/2023 at 1:00pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Administrator, Chioma "Abigail: Okpara, and explained the purpose of the visit. The Administrator holds a certificate 6054129740 which expires on 10/30/2023. The facility’s fire clearance is approved for six (6) 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) bedrooms and three (3) bathrooms. One (1) bedroom is occupied by staff. No bodies of water was observed. A comfortable temperature is maintained at 75 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 110.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/09/2022. Emergency Disaster Plan was last posted on 09/04/2023. First aid kit was observed to be complete. Fire drill was last conducted on 08/01/2023. Continued on LIC809.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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 3

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: FAM CARE HOMES, LLC	FACILITY NUMBER: 079200997
	VISIT DATE: 11/02/2023

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 LIC809.

LPA reviewed two (2) staff files both have first aid and CPR certification. LPA also reviewed all five (5) residents' files which were current and complete.

LPA observed the following deficiencies:

At 2:00pm, LPA observed broken window in bathroom located in activity room.

LPA requested the following documents to be submitted to CCLD by 11/9/2023.

Resident Roster
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (last page)
Liability Insurance

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due date, and any repeat violations within 12-month period may result in civil penalties.

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/02/2023 02:40 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: FAM CARE HOMES, LLC	FACILITY NUMBER: 079200997
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (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 in having the bathroom window in repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/13/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit an invoice for window repair 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3