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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200687
Report Date: 10/29/2021
Date Signed: 10/29/2021 02:42:40 PM

Document Has Been Signed on 10/29/2021 02:42 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:EDEN ASSISTED LIVINGFACILITY NUMBER:
019200687
ADMINISTRATOR:TET, SAMUELFACILITY TYPE:
740
ADDRESS:18787 CARLTON AVETELEPHONE:
(510) 885-0557
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 6CENSUS: 5DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Samual TetTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/29/2021 at 1:20pm, Licensing Program Analysts (LPAs) L. Francisco and G. Clark arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Samuel Tet and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan.

The following deficiency was observed:
- At approximately 1:40pm LPAs observed hydrogen peroxide in residents bedroom.
- At approximately 1:42pm LPAs observed unlocked cleaning supplies in common bathroom.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.


Administrator left for an appointment and authorized Care Staff Nadine Gabbidon to sign. Exit interview conducted with Care Staff. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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Document Has Been Signed on 10/29/2021 02:42 PM - It Cannot Be Edited


Created By: Lizette Francisco On 10/29/2021 at 02:09 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: EDEN ASSISTED LIVING
FACILITY NUMBER: 019200687

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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. LPAs observed unlocked hydrogen peroxside and cleaning supplies which poses an immediate health, safety risk to persons in care.
POC Due Date: 10/30/2021
Plan of Correction
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Deficiency cleared during visit. LPAs observed Administrator removed items and locked items away.

In addition Administrator will conduct traiing with staff and submit record of training to CCL by 11/12/2021.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2021


LIC809 (FAS) - (06/04)
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