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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201110
Report Date:
01/20/2023
Date Signed:
01/20/2023 12:51:30 PM
Document Has Been Signed on
01/20/2023 12:51 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:
CATERED CARE
FACILITY NUMBER:
079201110
ADMINISTRATOR:
GUTIERREZ, JONATHAN
FACILITY TYPE:
740
ADDRESS:
1312 5TH AVE
TELEPHONE:
(925) 286-2221
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94518
CAPACITY:
4
CENSUS:
2
DATE:
01/20/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:06 AM
MET WITH:
Jonathan Gutierrez, Licensee
TIME COMPLETED:
01:02 PM
NARRATIVE
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On 01/20/2023 at 09:06 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Administrator Jonathan Gutierrez and explained the purpose of the visit.
During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks.
The following deficiency was observed during the visit:
Staff records were not stored at the facility
Resident Records were not stored at the facility
Water temperature measured at 123.2 degrees
Eggs stored in cabinet unrefrigerated
Three staff are not fingerprinted, and one is not associated
PUB 475 poster not correct size
Both outdoor exit passageways are blocked
Alarm malfunctioning and going off
The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/20/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/20/2023
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
6
Document Has Been Signed on
01/20/2023 12:51 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:
CATERED CARE
FACILITY NUMBER:
079201110
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/20/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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4
Based on observation, the licensee did not comply with the section cited above by having a malfutioning alarm which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/21/2023
Plan of Correction
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4
POC cleard durring visit.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by having the water temperature at 123.2 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/21/2023
Plan of Correction
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2
3
4
POC cleared durring visit.
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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/20/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/20/2023
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
01/20/2023 12:51 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:
CATERED CARE
FACILITY NUMBER:
079201110
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/20/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above by not having staff records stored at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/27/2023
Plan of Correction
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The facility will complete each staff records and store them at the facility. Proof of correction will be sent to CCLD by POC date.
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having three staff who are not fingerprinted or associated and one staff who is not associated which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/27/2023
Plan of Correction
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Administrator removed S1, S2, and S3 immediately and will submit a signed statement stating all three are removed and will not be allowed to work until they are fingerprint cleared. Administrator will submit LIC 9182 and a copy of identifcation for S4.
Civil Penalty of $2000 is accessed.
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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/20/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/20/2023
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
01/20/2023 12:51 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:
CATERED CARE
FACILITY NUMBER:
079201110
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/20/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by not having records stored at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/27/2023
Plan of Correction
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2
3
4
The facility will complete each resident records and store them at the facility. copies of each resident record will be sent to CCLD by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/20/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/20/2023
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
01/20/2023 12:51 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:
CATERED CARE
FACILITY NUMBER:
079201110
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/20/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by not having PUB 475 in the correct size which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/03/2023
Plan of Correction
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2
3
4
The facility will print the poster in the correct size (20” x 26” in size) and post it where it is visable to staff and residents by POC date and send proof to CCLD
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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/20/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/20/2023
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
01/20/2023 12:51 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:
CATERED CARE
FACILITY NUMBER:
079201110
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/20/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.
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 storing eggs in the dry foods cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/27/2023
Plan of Correction
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2
3
4
Licensee will dispose of eggs immediately and repurchased. A copy of receipt will be sent to CCLD of food purchase 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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/20/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/20/2023
LIC809
(FAS) - (06/04)
Page:
6
of
6