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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440165
Report Date: 12/10/2021
Date Signed: 12/10/2021 03:47:21 PM

Document Has Been Signed on 12/10/2021 03:47 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:ABRAHAM REST HOMEFACILITY NUMBER:
071440165
ADMINISTRATOR:ABRAHAM, SARAFACILITY TYPE:
740
ADDRESS:116 VIA MONTETELEPHONE:
(925) 944-5218
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sara AbrahamTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit to staff members. LPA then began his tour of the facility inside and out after which he met with Licensee Sara Abraham who had arrived. The facility has a completed COVID-19 mitigation plan (LIC 808) and the LPA observed that staff are following all of the Department and Public Health Covid-19 infection control guidelines, including screening of all visitors and staff, all staff wearing face masks, and Covuid-19 signs at the entry point for visitors and throughout the facility to promote hand washing, cough and sneeze etiquette, physical distancing, and mask wearing.

High level of care was provided to the residents. There were sufficient supplies of food and PPE. The temperature within the facility was maintained at a comfortable level. A certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operation.

The facility was cited for two deficiencies:
  • Type A: hot water temperature measured at 135 degrees F
  • Type B: repairing and cleaning in the outside and inside of the facility

An exit interview conducted and a copy of this report was provided to the Licensee.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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 3
Document Has Been Signed on 12/10/2021 03:47 PM - It Cannot Be Edited


Created By: James Sampair On 12/10/2021 at 02:11 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: ABRAHAM REST HOME
FACILITY NUMBER: 071440165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 in keeping the facility in good repair at all times, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2022
Plan of Correction
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Send LPA proof of repairs of securely connecting the side fence to exterior of the building, tighten loose handles on cabinets and drawers, repair broken screen doors, and install missing alarm electrical connectors. Also needed is outdoor cleaning that includes at a minimum the removal of the following: refuse between shed and fence, glass bottles, bricks, chunks of concrete, old recycling plastic bottles on side of building, furniture pieces, and dead leaves.
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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/10/2021 03:47 PM - It Cannot Be Edited


Created By: James Sampair On 12/10/2021 at 02:51 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: ABRAHAM REST HOME
FACILITY NUMBER: 071440165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

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 with hot water measured at 135 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2021
Plan of Correction
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Reduce temperature so it is between 105 and 120 degrees F.
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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021


LIC809 (FAS) - (06/04)
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