079201195-2-22-2024-15-AS-CFOR-D2Q34A-20240222165449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201195
Report Date: 02/22/2024
Date Signed: 02/22/2024 04:55:01 PM

Document Has Been Signed on 02/22/2024 04:55 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:	SCARLET HOUSE FOR THE ELDERLY		FACILITY NUMBER:	079201195
ADMINISTRATOR:	WHITE, RACHEL		FACILITY TYPE:	740
ADDRESS:	5111 PAUL SCARLET DRIVE		TELEPHONE:	(650) 580-3239
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 4	DATE:	02/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	CARRENE CORONEL, CAREGIVER		TIME COMPLETED:	05:30 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 2/22/2024 at 2:00PM, Licensing Program Analyst (LPA) C. Fowler conducted an unannounced 1-Year Required inspection. LPA met with Carrene Coronel and Jose Coronel Caregivers, and explained the purpose of the visit. LPA spoke to Administrator Rachel White via phone she currently holds a certificate (#6055660740) that expired on 11/01/2024. LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, and back and side yard. The facility consists of six (6) total and three (3) bathrooms. A comfortable temperature is maintained. 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 114.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/07/2023. Emergency Disaster Plan was posted. First aid kit was observed to be complete. LPA reviewed 4 staff file which were complete and 4 resident files incomplete. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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: SCARLET HOUSE FOR THE ELDERLY	FACILITY NUMBER: 079201195
	VISIT DATE: 02/22/2024

NARRATIVE

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continue from LIC 809

LPA observed the following deficiencies:

· At 2:05pm, LPA observed staff not associated to the facility.
· At 2:10pm, LPA observed not enough food.
· At 2:15pm, LPA observed no current fire or disaster drill.

At 2:20pm, LPA observed all resident records are missing appraisal needs and service plans. (ANS)

LPA requested the following documents to be submitted to CCLD by 2/29/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

Deficiency is cited per Title 22 California Code of Regulations and listed on Lic 809D.

Exit interview conducted; Appeal Rights provided/

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/22/2024 04:55 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: SCARLET HOUSE FOR THE ELDERLY	FACILITY NUMBER: 079201195
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not conducting emergency disaster drills quarterly which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	Administrator agreed to conduct a disaster drill, document and email a copy of document to CCLD no later than the POC date.

Type B

Section Cited

CCR

80019(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by having staff/volunteer working and not associated to the facility which poses a potential health and safety or risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	Administrator agreed to transfer criminal record and associate staff to the facility by POC date.

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/22/2024 04:55 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: SCARLET HOUSE FOR THE ELDERLY	FACILITY NUMBER: 079201195
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85076

The licensee shall meet the following food supply and storage requirements: Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: 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 enough food supply which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	Administrator agreed to purchase additional groceries and provide CCLD a copy of the receipt and photos of the food purchased by POC date.

Type B

Section Cited

CCR

87506

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having complete resident files which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	Administrator will complete appraisal needs and service plans for all residents and email mail a copy to CCLD by POC date

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

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