079201065-4-19-2023-15-AS-LIBO-CR2SCR-20230419134557

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201065
Report Date: 04/19/2023
Date Signed: 04/19/2023 01:46:20 PM

Document Has Been Signed on 04/19/2023 01:46 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:	OAKLEY ASSISTED LIVING II , LLC		FACILITY NUMBER:	079201065
ADMINISTRATOR:	LAKE, NICOLETTE		FACILITY TYPE:	740
ADDRESS:	1449 BUTTONS CT		TELEPHONE:	(925) 219-6165
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 5	DATE:	04/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	NICOLETTE LAKE, Administrator		TIME COMPLETED:	02:05 PM

NARRATIVE

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On 4/19/2023 at around 9:35AM, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct annual required inspection and greeted by staff (S2), after couple of minutes Administrator Nicollete Lake, arrived at the facility. LPA explained the purpose visit to S2 and to Administrator.

LPA toured the entire premises with Administrator Nicollete, including but not limited to indoors and outdoors. The facility has 6 bedrooms, 4 bathrooms including 1 staff bathroom, 3 residents’ bathrooms, single story house per facility sketch. Six (6) bedrooms are designated for residents. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 03/02/2021 with an approval for a total capacity of 6 residents, approved for 4 non-ambulatory & 2 bedridden for room number 5 & 2 only.

LPA inspected 6 rooms. The facility was observed to be clean and odor free. LPA observed fire extinguisher located at the kitchen area with service date of September 6, 2022.

There was sufficient supply of perishable and non perishable foods observed. Freezer temperature was observed at zero (0) degrees Fahrenheit. Refrigerator temperature measured at 40 degrees Fahrenheit. First aid kit was complete. Vehicle insurance and registration were verified as current.

LPA reviewed medication and Medication Administration Record (MAR) with facility Administrator.

...Continues to LIC809C...

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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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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: OAKLEY ASSISTED LIVING II , LLC	FACILITY NUMBER: 079201065
	VISIT DATE: 04/19/2023

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LPA interviewed 2 staff and 3 out of 5 residents. At around 11am, LPA reviewed 4 resident files and 3 staff files.

The following deficiencies were observed:
At around 9:46AM, LPA observed pair of scissors inside unlocked drawer.
At around 10:15AM, LPA observed unopened cleaning products stores with some food supplies.

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.

Exit interview was conducted with Administrator and Appeal Rights was provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/19/2023 01:46 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: OAKLEY ASSISTED LIVING II , LLC	FACILITY NUMBER: 079201065
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 staff failed to lock a pair of scissors, which was accesible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2023
	Plan of Correction
1 2 3 4	Corrected during the visit. staff locked the pair of scissors.

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: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/19/2023 01:46 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: OAKLEY ASSISTED LIVING II , LLC	FACILITY NUMBER: 079201065
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(25)

General Food Service Requirements

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. 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 failing to store cleaner solutions in area separate from non perishable foods which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2023
	Plan of Correction
1 2 3 4	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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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