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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200727
Report Date: 05/11/2022
Date Signed: 05/11/2022 05:35:45 PM

Document Has Been Signed on 05/11/2022 05:35 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:FLINTWOOD CARE HOMEFACILITY NUMBER:
019200727
ADMINISTRATOR:HOLT, JEANFACILITY TYPE:
740
ADDRESS:36614 FLINTWOOD DRIVETELEPHONE:
(510) 742-5680
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 2DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Jean Holt, AdministratorTIME COMPLETED:
05:45 PM
NARRATIVE
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On 5/11/2022 at 3:05PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Jean Holt.

Upon entry, staff did not conduct COVID-19 screening for LPA. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPA observed only cough etiquette posted in the common area. All sinks and bathrooms were equipped with soap and paper towel.

During record review, LPA observed visitors log and temperature log for residents. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient.

At 3:20PM, LPA observed unlocked cleaning supply under the kitchen sink. Administrator informed LPA that the lock is broken. LPA also observed unlocked gardening tool and paint thinner in the backyard. Administrator locked up paint thinner and gardening tool during inspection.

At 3:30PM, LPA observed a security lock located on the front door towards the top of the door. Administrator removed the security lock during inspection.

At 3:50PM, LPA observed S1's health screen shows that TB test was positive and did not have a chest x-ray.

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

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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 6
Document Has Been Signed on 05/11/2022 05:35 PM - It Cannot Be Edited


Created By: Grace Luk On 05/11/2022 at 04:50 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: FLINTWOOD CARE HOME
FACILITY NUMBER: 019200727

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

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 by having unlocked cleaning supplies, gardening tool, and paint thinner which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Administrator has locked up the gardening tool and paint thinner. Administrator has agreed to repair the lock under the kitchen sink and submit picture proof to CCLD by POC date.
Type A
Section Cited
HSC
87468.1(a)(6
87468.1 Personal Rights of Residents in All Facilities
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.

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 by having safety lock high on the front door which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Administrator have removed security lock during inspection.

Deficiency cleared.
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:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/11/2022 05:35 PM - It Cannot Be Edited


Created By: Grace Luk On 05/11/2022 at 04:50 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: FLINTWOOD CARE HOME
FACILITY NUMBER: 019200727

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

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
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Based on record review, the licensee did not comply with the section cited above by not having chest x-ray for S1 which poses a potential health and safety risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Administrator has agreed to obtain negative TB test or chest x-ray for S1 and submit a copy 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
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