079201142-3-17-2023-15-AS-LFRO-CPZVKN-20230317163038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201142
Report Date: 03/17/2023
Date Signed: 03/17/2023 04:30:59 PM

Document Has Been Signed on 03/17/2023 04:30 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:	EMMAUS HOMECARE INC.		FACILITY NUMBER:	079201142
ADMINISTRATOR:	BALMEO, MARCEL & QUENNIE		FACILITY TYPE:	740
ADDRESS:	3203 MUNRAS PLACE		TELEPHONE:	(650) 771-7909
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 3	DATE:	03/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Quennie Balmeo, Administrator		TIME COMPLETED:	04:45 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 3/17/2023 starting 9:50 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Holmes arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Quennie Balmeo and explained the purpose of the visit. The facility’s fire clearance was approved for all six (6) residents may be non-ambulatory. There were 2 staff and 3 residents present during inspection. Starting at 10:15 AM, LPAs toured facility with Administrator including but not limited to 6 bedrooms, 3 bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are for residents and 1 bedroom is for staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in 1 of 3 residents’ shared bathroom was measured at 111 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Three smoke detectors were tested and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 2/1/2023. Emergency Disaster Plan was last posted on 2/4/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 3/15/2023. At 2:00 PM, LPAs reviewed 3 residents records. At 11:05 AM LPAs reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. At 3:10 PM, LPAs reviewed a sample of resident’s medications. *REPORT CONTINUES ON 809C*

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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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Document Has Been Signed on 03/17/2023 04:30 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: EMMAUS HOMECARE INC.	FACILITY NUMBER: 079201142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 preparing medications in pill boxes for a couple of days in advance which poses a potential health and safety risks to persons in care.
	POC Due Date: 03/20/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to discontinue preparing R3's medication and review medication, and submit a self-certification letter to CCLD.

Type B

Section Cited

CCR

87618(b)(3)(E)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. 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 not having two oxygen tank R1's bedroom closet which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 03/20/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will secure oxygen tanks in a stand and submit a photo 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: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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: EMMAUS HOMECARE INC.	FACILITY NUMBER: 079201142
	VISIT DATE: 03/17/2023

NARRATIVE

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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
-At 10:25 AM, LPAs observed two oxygen tanks in R3's bedroom close not secured
-At 3:10 PM, LPAs observed medication prepared in pill boxes for R3

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/24/2023:

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

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC809 (FAS) - (06/04)

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