079201040-6-6-2022-15-AS-LIBO-CF5RN4-20220606130942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201040
Report Date: 06/06/2022
Date Signed: 06/06/2022 01:10:49 PM

Document Has Been Signed on 06/06/2022 01:10 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:	CATHEDRAL CARE HOME		FACILITY NUMBER:	079201040
ADMINISTRATOR:	DATUIN, MARIVIC		FACILITY TYPE:	740
ADDRESS:	2707 CATHEDRAL CIRCLE		TELEPHONE:	(925) 222-8492
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 5	DATE:	06/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Marivic Datuin, Administrator		TIME COMPLETED:	01:20 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 6/6/2022 at 10:45 AM, Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and explained the purpose of the visit with Administrator Marivic Datuin. Facility has census of 5. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 76 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational. Hot water temperature was observed to be at 112.5 degrees Fahrenheit. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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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Document Has Been Signed on 06/06/2022 01:10 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: CATHEDRAL CARE HOME	FACILITY NUMBER: 079201040
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 medication was accessible to resident/s in care, disinfectant cleaner accessible to resident in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2022
	Plan of Correction
1 2 3 4	Administrator locked the disinfectant supplies and medications supplies. Corrected during the 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC809 (FAS) - (06/04)

Page: 2 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: CATHEDRAL CARE HOME	FACILITY NUMBER: 079201040
	VISIT DATE: 06/06/2022

NARRATIVE

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LPA observed the following:

· LPA observed medications accessible to residents in care.

· At 10:49 AM LPA observed cleaning products (Clorox spray) under unlocked kitchen cabinet

· LPA strongly recommended N95 FIT testing for all staff. (technical assistance).

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

Deficiencies and plan and proof of corrections were discussed with Marivic Datuin.

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC809 (FAS) - (06/04)

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