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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200660
Report Date: 06/23/2021
Date Signed: 06/23/2021 11:23:08 AM

Document Has Been Signed on 06/23/2021 11:23 AM - 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:VERMONTCARE LLCFACILITY NUMBER:
019200660
ADMINISTRATOR:MAGLONG, ROSELI PFACILITY TYPE:
740
ADDRESS:865 VERMONT STREETTELEPHONE:
(510) 835-3632
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 10CENSUS: DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Roseli MaglongTIME COMPLETED:
11:30 AM
NARRATIVE
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On 06/23/2021 at 9:07am, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Licensee Roseli Maglong and explained the purpose of the visit.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and courtyard. LPA observed cough etiquette and COVID-19 symptoms signs posted in the common areas. Hand washing signs are in bathrooms.

LPA observed food and paper supplies are sufficient. Sign-in and temperature log were maintained at the facility for all visitors. Common areas are disinfected every day.

During record review, LPA observed facility has a copy of Mitigation Plan, but has not submitted the plan to CCLD.

LPA did not observe a working carbon monoxide detector at the facility.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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 3
Document Has Been Signed on 06/23/2021 11:23 AM - It Cannot Be Edited


Created By: Allison O'Hollaren On 06/23/2021 at 10:58 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: VERMONTCARE LLC
FACILITY NUMBER: 019200660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
1503.2 Carbon monoxide detectors required; inspection
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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. LPA observed no working carbon monoxide detectors in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2021
Plan of Correction
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Licensee agrees to install a working carbon monoxide detector and submit a picture to CCL 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/23/2021 11:23 AM - It Cannot Be Edited


Created By: Allison O'Hollaren On 06/23/2021 at 11:00 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: VERMONTCARE LLC
FACILITY NUMBER: 019200660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80064(a)(3)
80064 Administrator - Qualifications and Duties
(a) The administrator shall have the following qualifications:
(3) Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Licensee stated a mitigation plan was not submitted to CCL for facility per PIN 20-48-ASC which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2021
Plan of Correction
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Licensee agrees to submit LIC808 to CCL by fax or email by POC date.
Section Cited
Deficient Practice Statement
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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:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
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