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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200727
Report Date: 01/02/2025
Date Signed: 01/02/2025 12:27:46 PM

Document Has Been Signed on 01/02/2025 12:27 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:FLINTWOOD CARE HOMEFACILITY NUMBER:
019200727
ADMINISTRATOR/
DIRECTOR:		HOLT, JEANFACILITY TYPE:
740
ADDRESS:36614 FLINTWOOD DRIVETELEPHONE:
(510) 742-5680
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 2DATE:
01/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jean Holt, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 01/02/2025 at 9:00 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Jean Holt, and explained the purpose of the visit. Administrator certificate is current and expires on 05/12/2025.

LPAs toured facility with inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 3 bedrooms are occupied by the residents and 2 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. 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 residents’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. 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 purchased on 04/16/2024. Emergency Disaster Plan was last posted on 01/02/2025. First aid kit was observed to be complete. Fire Drill drill was last conducted on 12/01/2024.

At 9:16 AM, LPA reviewed 2 residents records. At 9:30 AM, LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility. At 11:20 AM, LPA reviewed all of the resident’s medications. All records were observed to be complete and up to date.

Continue to LIC 809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FLINTWOOD CARE HOME
FACILITY NUMBER: 019200727
VISIT DATE: 01/02/2025
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/09/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:20 AM, LPAs observed unlocked chemicals under the kitchen sink.

At 9:23 AM, LPAs observed unlocked eye drops and insulin in the kitchen fridge.

At 9:35 AM, LPAs observed the left side gate with a second sliding bolt. Civil penalty of $500 is being assessed.

At 9:45 AM, LPAs observed unlocked medication in R1's closet.


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.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/02/2025 12:27 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/02/2025 at 12:00 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: 01/02/2025

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
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Based on observation, the Administrator did not comply with the section cited above in having the left side gate with a sliding bolt lock which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Administrator agrees to remove the sliding bolt lock and send proof to CCLD by POC date. Civil Penalty of $500 is assessed.
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
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Based on observation, the Administrator did not comply with the section cited above in having chemicals under the kitchen sink and bathroom sink unlocked and accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Staff locked the chemicals during the visit. Deficiency cleared during the visit.
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: 01/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/02/2025 12:27 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/02/2025 at 12:00 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: 01/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in having eye drops and insulin found in the fridge and medication found in R1’s closet unlocked and accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Staff locked the medications during the visit. Deficiency cleared during the visit.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2025


LIC809 (FAS) - (06/04)
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