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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601051
Report Date: 12/22/2021
Date Signed: 12/22/2021 05:58:40 PM

Document Has Been Signed on 12/22/2021 05:58 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:LA CONCEPCION RESIDENTIAL CARE HOMEFACILITY NUMBER:
015601051
ADMINISTRATOR:CONCEPCION, CRISTINAFACILITY TYPE:
740
ADDRESS:4419 JACINTO DRTELEPHONE:
(510) 574-0755
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 4DATE:
12/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Cristina ConcepcionTIME COMPLETED:
06:30 PM
NARRATIVE
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On 12/22/2021 Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a case management inspection due to another visit. LPA met with S2, LPA called Administrator Cristina Concepcion, Administrator arrived after 20 mins.

LPA toured facility inside and outside. LPA observed 4 residents in care, 3 are on hospice and 1 non-ambulatory resident.

…Continued on LIC809C…

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051
VISIT DATE: 12/22/2021
NARRATIVE
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The following was observed during facility visit:

Disinfectant cleaning was observed accessible to residents in care- cleared

S2 do not have fingerprint clearance.

S3 is not associated at the facility.- cleared

S2 & S3 do not have the following on their employee file; health screening LIC503, TB test, Criminal records statement (LIC508) & employee rights (LIC 9052).

No grab bar available for resident in care in bathroom #3.

Failed to report unusual incident to CCL office.

$500.00 Civil penalty was assessed during the visit.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.



Exit interview conducted. Appeal Rights and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/22/2021 05:58 PM - It Cannot Be Edited


Created By: Leslie Ibo On 12/22/2021 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2021
Section Cited
CCR
80087(g)

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Buildings and Grounds Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients..
This requirement is not met as evidence by:
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Cleared during the visit.
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Based on observation the licensee did not comply with the section cited above disinfectant solution was observed accesible to residents in care which poses a potential health and safety risk to the residents in care.
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Type A
12/22/2021
Section Cited
CCR87355(e)

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Criminal Record Clearance. All individuals subject to a criminal record review...prior to working, residing or volunteering in a licensed facility: Obtain a California clearance...
This requirement is not met as evidence by:
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Administrator will obtain criminal record clearance for S2. S2 cannot assist residents ADL if a fingerprint staff is not present. Administrator will submit a copy of S1's criminal record clearance to CCLD.
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Based on interview and records review licensee failed to have criminal record clearance for S2 which poses an immediate health and safety risk to the residents in care.
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LPA provided technical assistance to Administrator about using guardian system for easier access of fingerprint clearance for the facility.
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
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/22/2021 05:58 PM - It Cannot Be Edited


Created By: Leslie Ibo On 12/22/2021 at 04:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2021
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance Request a transfer of a criminal record clearance as specified in Section…
This requirement is not met as evidence by:
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Cleared. Adminsitrator associated S3.
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Based on investigation, the licensee did not comply with the section cited above S3 is not associated with the facility which poses a potential health and safety risk to the residents in care.
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Type B
01/07/2022
Section Cited
CCR80065(g)(1)

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Personnel Requirements. Good physical health shall be verified by a health screening, including a test for tuberculosis, performed under the supervision of a physician not more than one year prior to or seven days .

This requirement is not met as evidence by:
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Administrator/Licensee needs to send staff s2 & S3 for health screening and TB testing, Adminsitrator needs to send proof of health screening and TB test to CCL office by POC date.
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Based on interview with Adminsitrator and records review, LPA observed no health screening and TB test results for Staff 1 (S2 & S3) which poses a potential health and safety risk to the residents in care.
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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
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/22/2021 05:58 PM - It Cannot Be Edited


Created By: Leslie Ibo On 12/22/2021 at 04:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2022
Section Cited
CCR
87303(e)(4)

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Maintenance and Operation. Grab bars shall be in each toilet used by residents.
This requirement is not met as evidenced by
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The licensee/Administrator shall purchase and install appropriate grab bar on all toilet use by residents, Administrator/Licensee shall take picture and send to CCL as proof of correction by POC date.
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Based upon observation, the licensee does not have grab bars near the toilet for client use.
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Type B
01/03/2022
Section Cited
CCR87211(a)(1)(D)

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Reporting Requirements:(a) Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident..
This requirement was not met as evidence by:
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The licensee will submit a written plan which describes what steps will be taken in order to ensure that unusual incidents are reported to CCL per Title 22 regulations, by the POC date
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Based on record review and interview, Licensee did not comply with the regulation cited above, Administrator admitted that she did not submit unusual incident report for R1’s hospitalization, administrator also mentioned that she “does not know” that she needs to submit such report.
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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
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
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