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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601051
Report Date: 03/20/2024
Date Signed: 03/20/2024 06:47:53 PM

Document Has Been Signed on 03/20/2024 06:47 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: 2DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Cristina ConcepcionTIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with Administrator Cristina Concepcion. LPA explained to the Administrator the purpose of the visit.

During the visit, LPA inspected the facility inside and out including but not limited to resident rooms, bathrooms, kitchen, dining, garage and backyard. Hot water measured at 138.5 Fahrenheit. There was sufficient supply of perishable and non perishable foods. LPA observed sufficient supply of warm blankets, sheets and towels available for use of the residents. Smoke detectors and carbon monoxide were tested and observed functional. First aid kit was observed to be complete.
LPA reviewed 2 resident and 2 staff files. LPA interviewed 2 staff and one resident.

The following deficiencies were observed:
  • hot water measured at 135 degrees Fahrenheit
  • Both staff on duty did not have any first aid training
  • window screen/screen door observed taped and with holes
  • no proof of staff training on file
  • unused equipment, commodes, wood planks, etc were observed on the side
  • fire extinguisher was last inspected on 7/8/2021
  • R2 has dementia and last medical assessment was made in 2022
  • missing staff and resident records were observed
  • S2 does not have TB test and health screening on file

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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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Document Has Been Signed on 03/20/2024 06:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/20/2024 at 05:16 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: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review conducted, the licensee did not comply with the section cited above in having R2 work without TB test and health screening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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By POC date, Administrator will have S2 get TB test and do health screening and submit proof to CCL.

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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 16
Document Has Been Signed on 03/20/2024 06:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/20/2024 at 05:16 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: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review conducted, the licensee did not comply with the section cited above in not having First aid training for both staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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By POC date, both staff will complete first aid training and submit proof to CCL.
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water at 135 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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By POC date, Administrator will adjust hot water temperature within range and submit self-certificate of completion to CCL.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 16
Document Has Been Signed on 03/20/2024 06:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/20/2024 at 05:44 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: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


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 in having screen door/window with hole/ripped, fire extinguisher not updated with inspection, having commodes, pieces of wood, mattress etc on the side and backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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By POC date, Administrator will submit photo proof of completion to CCL.
Type B
Section Cited
CCR
87705(5)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, R1 who has dementia does not have an updated medical assessment. Last assessment is dated 2022.
POC Due Date: 04/03/2024
Plan of Correction
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Administrator will have R1 obtain an updated medical assessment and submit proof to CCL.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2024 06:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/20/2024 at 06:03 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: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on file review, the licensee did not comply with the section cited above in not having proof of staff training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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By POC date, Administrator will submit to CCL proof of staff training.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
Page: 5 of 16
Document Has Been Signed on 03/20/2024 06:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/20/2024 at 06:05 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: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on file review codnucted, the licensee did not comply with the section cited above in not having doctor's order for R2's 1/2 rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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The administrator will submit to CCL doctor's order for R2's 1/2 rails.
Type B
Section Cited
CCR
87506(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review codnucted, the licensee did not comply with the section cited above in not having complete resident records on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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By POC date, Adinistrator will update all residents' files and submit self-certification of completion to CCL.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2024 06:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/20/2024 at 06:22 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: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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
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2
3
4
Based on file review, the licensee did not comply with the section cited above in not conducting fire drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator will conduct emergency drill and submit proof to CCL.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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