079201079-10-9-2023-15-AS-PWAN-CWFTG4-20231009144231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201079
Report Date: 10/09/2023
Date Signed: 10/09/2023 02:42:37 PM

Document Has Been Signed on 10/09/2023 02:42 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	TERESA'S QUALITY COMFORT CARE, LLC		FACILITY NUMBER:	079201079
ADMINISTRATOR:	BOATNER, SALINA		FACILITY TYPE:	740
ADDRESS:	1786 CONCANNON DR		TELEPHONE:	(925) 206-1947
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 4	DATE:	10/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Salina Boatner, Administrator		TIME COMPLETED:	03:00 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 10/09/2023 at 12:15 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by caregiver, Administrator arrived at 1:00 PM. LPA met with Administrator, Salina Boatner and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory which 1 may be Bedridden. LPA toured facility with Salina including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which all 3 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 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 108 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last purchased on 06/18/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/28/2023. Report continues on 809 C.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TERESA'S QUALITY COMFORT CARE, LLC	FACILITY NUMBER: 079201079
	VISIT DATE: 10/09/2023

NARRATIVE

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At 1:10 PM, LPA reviewed 4 of 4 residents records. At 1:35 PM, LPA reviewed 5 of 5 staff records and 5 of 5 have current first aid training and associated to the facility. At PM, LPA reviewed 4 of 4 resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/30/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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