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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
015601051
Report Date:
03/07/2025
Date Signed:
03/07/2025 03:44:47 PM
Document Has Been Signed on
03/07/2025 03:44 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
OAKLAND ASC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER:
015601051
ADMINISTRATOR/
DIRECTOR:
CONCEPCION, CRISTINA
FACILITY TYPE:
740
ADDRESS:
4419 JACINTO DR
TELEPHONE:
(510) 574-0755
CITY:
FREMONT
STATE:
CA
ZIP CODE:
94536
CAPACITY:
6
CENSUS:
4
DATE:
03/07/2025
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:
Cristina Concepcion, Administrator
TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 03/07/2025 at 11:30 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Cristina Concepcion, and explained the purpose of the visit. Administrator certificate is current and expires on 12/10/2026. The facility’s fire clearance was approved for only four (4) may be non-ambulatory and hospice waiver of three (3) .
LPAs toured facility with Administrator inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. 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 the resident's bathroom was measured at 129.1 degrees Fahrenheit. Both residents’ bathrooms are equipped with grab bars, non-skid mats, and non-skid shower pans. There is a minimum of one week supply of nonperishable and 2-day of perishable foods.
Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 03/25/2024. First aid kit was observed to be complete.
At 12:16 PM, LPAs reviewed 4 residents records. At 12:42 PM, LPA reviewed 4 staff records. At 2:00 PM, LPA reviewed two sample of residents' medications.
Continue to LIC809-C...
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
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
12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER:
015601051
VISIT DATE:
03/07/2025
NARRATIVE
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Continue from LIC809...
THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
At 11:50 AM, LPA observed the hot water temperature measured at 129.1 degrees Fahrenheit.
At 12:02 PM, LPA observed oxygen tanks, portable oxygen machine, crutches, commode, bbq pit, etc in the backyard that needs to be removed.
At 12:04 PM, LPA observed that the self closing latch was tied with the string to keep it locked.
At 12:15 PM, LPA observed a knife in one of the kitchen drawers.
At 1:12 PM, LPA observed that 24 have incomplete staff files in record.
At 1:13 PM, LPA observed the Emergency Disaster Plan incomplete and not filled out.
At 1:24 PM, LPA observed that S4 did not have a TB test on file.
At 1:30 PM, during record review, LPA observed no drills conducted.
At 1:32 PM, LPA observed that S2 to S4 does not have a First Aid Certification.
At 1:33 PM, LPA did not observe a complaint poster.
At 1:42 PM, LPA observed that S4 was not associated to the facility.
At 1:44 PM, LPA observed that R2 and R4 have half bed rail and did not have doctor's order on file.
At 1:45 PM, LPA observed that R3 have full bed rails.
At 1:47 PM, LPA observed that R1 to R4's files was incomplete on file.
The Facility was 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.
Civil Penalties Assessed for today's visit.
Exit interview conducted with Licensee. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
2
of
12
Document Has Been Signed on
03/07/2025 03:44 PM
- It Cannot Be Edited
Created By:
Patricia Manalo
On
03/07/2025
at
02:20 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:
03/07/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
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 in having the self closing latch tied with the string to lock the gate which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/08/2025
Plan of Correction
1
2
3
4
Administrator untied the string during the visit. Deficiency cleared.
Civil Penalty of $500 is assessed.
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
1
2
3
4
Based on observation the licensee did not comply with the section cited above in having the hot water measured at 129.1 degrees which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/08/2025
Plan of Correction
1
2
3
4
The licensee agrees to have the hot water temperature measured within range and send proof 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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
3
of
12
Document Has Been Signed on
03/07/2025 03:44 PM
- It Cannot Be Edited
Created By:
Patricia Manalo
On
03/07/2025
at
02:20 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:
03/07/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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 in having a knife found in one of the kitchen drawers which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/08/2025
Plan of Correction
1
2
3
4
The licensee agrees to lock the knives in the cabinet and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
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:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
4
of
12
Document Has Been Signed on
03/07/2025 03:44 PM
- It Cannot Be Edited
Created By:
Patricia Manalo
On
03/07/2025
at
02:20 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:
03/07/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having a TB test for S4 which poses a potential health and safety risk to persons in care.
POC Due Date:
03/28/2025
Plan of Correction
1
2
3
4
The licensee agrees to have staff get TB test and send proof 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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
5
of
12
Document Has Been Signed on
03/07/2025 03:44 PM
- It Cannot Be Edited
Created By:
Patricia Manalo
On
03/07/2025
at
02:20 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:
03/07/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having oxygen tanks, portable oxygen machine, crutches, commode, BBQ pit, etc in the backyard that needs to be removed which poses a potential health and safety risk to persons in care.
POC Due Date:
03/21/2025
Plan of Correction
1
2
3
4
The licensee agrees to schedule a bulk removal and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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 in having the passageway in front of the garage door blocked with toilet paper, TV, ladder, etc which poses a potential health and safety risk to persons in care.
POC Due Date:
03/14/2025
Plan of Correction
1
2
3
4
The licensee agrees to clear the passageway and send proof 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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
6
of
12
Document Has Been Signed on
03/07/2025 03:44 PM
- It Cannot Be Edited
Created By:
Patricia Manalo
On
03/07/2025
at
02:20 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:
03/07/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
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: (3) 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in not having S4 associated to the facility which poses a potential health and safety risk to persons in care.
POC Due Date:
03/14/2025
Plan of Correction
1
2
3
4
The licensee agrees to have S4 associated to the facility and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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 in not having First Aid Certification for S2 to S4 which poses a potential health and safety risk to persons in care.
POC Due Date:
03/21/2025
Plan of Correction
1
2
3
4
The licensee agrees to obtain First Aid Certification for S2 to S4 and send proof 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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
7
of
12
Document Has Been Signed on
03/07/2025 03:44 PM
- It Cannot Be Edited
Created By:
Patricia Manalo
On
03/07/2025
at
02:20 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:
03/07/2025
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in not having the Complaint poster which poses a potential health and safety risk to persons in care.
POC Due Date:
03/14/2025
Plan of Correction
1
2
3
4
The licensee ordered the poster on this date and will send proof of the poster 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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
8
of
12
Document Has Been Signed on
03/07/2025 03:44 PM
- It Cannot Be Edited
Created By:
Patricia Manalo
On
03/07/2025
at
02:20 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:
03/07/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:
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 in having R1 to R4 resident files incomplete which poses a potential health and safety risk to persons in care.
POC Due Date:
03/28/2025
Plan of Correction
1
2
3
4
The licensee agrees to complete all the resident's files and send proof to CCLD by POC date.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:
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 in not having the Emergency Disaster Plan incomplete and not filled out which poses a potential health and safety risk to persons in care.
POC Due Date:
03/28/2025
Plan of Correction
1
2
3
4
The licensee agrees to complete the Emergency Disaster Plan and send proof 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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
9
of
12
Document Has Been Signed on
03/07/2025 03:44 PM
- It Cannot Be Edited
Created By:
Patricia Manalo
On
03/07/2025
at
02:20 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:
03/07/2025
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
1
2
3
4
Based on record review the licensee did not comply with the section cited above by not conducting quarterly drills which poses a potential health and safety risk to persons in care.
POC Due Date:
03/28/2025
Plan of Correction
1
2
3
4
The licensee agrees to conduct a drill and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
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 in half bed rails for R2 and R4 which poses a potential health and safety risk to persons in care.
POC Due Date:
03/28/2025
Plan of Correction
1
2
3
4
The licensee agrees to obtain the doctor's order for the half bed rails and send proof 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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
10
of
12
Document Has Been Signed on
03/07/2025 03:44 PM
- It Cannot Be Edited
Created By:
Patricia Manalo
On
03/07/2025
at
02:20 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:
03/07/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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 in having a full bed rail for R3 which poses a potential health and safety risk to persons in care.
POC Due Date:
04/04/2025
Plan of Correction
1
2
3
4
The licensee will send an exception request and send to CCLD 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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE:
03/07/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/07/2025
LIC809
(FAS) - (06/04)
Page:
11
of
12