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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071405691
Report Date: 05/09/2024
Date Signed: 05/09/2024 02:50:52 PM

Document Has Been Signed on 05/09/2024 02:50 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ABRAHAM REST HOMEFACILITY NUMBER:
071405691
ADMINISTRATOR/
DIRECTOR:		ABRAHAM, SARAFACILITY TYPE:
740
ADDRESS:14 LOMMEL COURTTELEPHONE:
(925) 944-9594
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 8CENSUS: 6DATE:
05/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Annette Sanchez, Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 05/09/2024 at 1:30 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an Resident's (R1) Physician's Report that was received by CCLD. LPA met with Blanca Cuestas and explained the purpose of the visit. Blanca phoned, Co-Administrator, Annette Sanchez, who arrived to the facility shortly.

During Annual Visit on 01/03/2024 R1 was missing her Physician's Report with physician's signature. Administrator submitted R1's Physician's Report to LPA L. Alexander via email on 03/05/2024 and the report had a restricted health condition; Foley Catheter. LPA responded to Administrator and asked who was caring for the catheter and Administrator stated that R1 has home health. LPA emailed Administrator on 04/08/24 to advise that R1 will need an exception request for the restricted health condition and to submit the required documents by 04/12/24.

LPA spoke with Administrator who stated that R1 no longer has the Foley Catheter and only had a temporary issue with her kidneys. LPA observed R1 sitting in the TV room and she did not have a catheter. LPA advised Administrator to update R1's Physician's Report and also Appraisal Needs and Services.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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