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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601478
Report Date: 10/22/2022
Date Signed: 10/22/2022 12:12:58 PM

Document Has Been Signed on 10/22/2022 12:12 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:ST JOSEPH SENIOR CAREFACILITY NUMBER:
015601478
ADMINISTRATOR:ZENAIDA C BAUTISTAFACILITY TYPE:
740
ADDRESS:6437 DAPHNE CTTELEPHONE:
(510) 795-7603
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 3DATE:
10/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Zenaida Bautista, AdministratorTIME COMPLETED:
12:45 PM
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On 10/22/2022 at 10:00AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Zenaida Bautista, and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs posted near screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Fire extinguisher last serviced on 2/22/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed facility has a copy of the mitigation plan on file. LPA observed food and paper supplies are sufficient.

The following deficiencies were observed:
  • At 10:26AM, LPA observed scissors on the living room table.
  • At 10:27AM, LPA observed key in the overflow medication drawer and an unlocked lock on the medication cart.
  • At 10:28AM, during observation unlocked medication on a shelf in the dining room.
  • At 10:26AM, LPA observed knife drying in dish rack and 1 on the kitchen counter.
Continue on LIC809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2022
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: ST JOSEPH SENIOR CARE
FACILITY NUMBER: 015601478
VISIT DATE: 10/22/2022
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Continue from LIC 809
  • At 10:34AM, LPA observed Clorox toilet cleaner no more making pet spray in an unlocked cabinet in the shared bathroom.
  • At 10:43AM, LPA observed All laundry detergent, ultra soft fabric softner, Lysol, unstopables laundry beads, and WD40 located in the unlocked garage.
  • At 10:47AM, LPA observed a shovel, 2 beds covered with a tarp, vigoro garden soil, and hedge trimmers located in the backyard.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.



Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2022 12:12 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/22/2022 at 11:48 AM
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: ST JOSEPH SENIOR CARE
FACILITY NUMBER: 015601478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(1)(a)
(1) 87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Storage areas for poisons... shall be locked.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation licensee did not comply with the section cited above by having Clorox toilet cleaner, no more making pet spray, All laundry detergent, ultra soft fabric softner, lysol, unstopables, WD40, scissors, unlocked medication, knifts, shovel, beds vigoro garden soil, hedge trimmers, accessible to residents which poses an immediate health and safety risk do to persons in care
POC Due Date: 11/14/2022
Plan of Correction
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POC: Administrator agreed to store cleaners, medications, knifts and scissors in a locked cabnet. Administrator will also conduct an inservice with staff on the importance of keeping cleaning sollutions, poisons, disinfectants and other items which could pose a danger to residents in care and submit signed certification along with photos of corrections to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2022


LIC809 (FAS) - (06/04)
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