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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071405691
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:15:07 PM

Document Has Been Signed on 12/10/2024 03:15 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:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Sara Abraham, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 12/10/2024 at 11:10 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator/Licensee, Sara Abraham and explained the purpose of the visit. Co-Administrator, Annette Sanchez arrived shortly after. The facility’s fire clearance was approved for capacity eight (8) non-ambulatory. Hospice waiver for two (2) residents. Administrator Certificate #6006207740 expires 04/16/2025.

LPA toured facility with Annette including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of ten (10) total bedrooms which eight (8) bedrooms are occupied by the residents and two (2) bedrooms is 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 75 degrees Fahrenheit. LPA 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 degrees 106.5 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. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/10/2024. Emergency Disaster Plan was last posted on 12/10/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on December 2024.


LIC809-C Continued....
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 071405691
VISIT DATE: 12/10/2024
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LIC809-C (Page 2)

LPA reviewed six (6) residents records. LPA reviewed seven (7) staff records and seven (7) of seven (7) have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/17/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan - Reviewed
Certificate of Liability Insurance - Reviewed

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
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