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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600618
Report Date: 02/23/2023
Date Signed: 02/23/2023 02:44:59 PM

Document Has Been Signed on 02/23/2023 02:44 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:
075600618
ADMINISTRATOR:ANNETTE SANCHEZFACILITY TYPE:
740
ADDRESS:2832 FILBERT DRIVETELEPHONE:
(925) 287-8382
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Annette SanchezTIME COMPLETED:
03:00 PM
NARRATIVE
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On 02/23/2023 at 12:15 PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with Administrator (ADM) Annette Sanchez.

LPA inspected the facility inside and outside. Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. Adequate supplies of PPE were stored on the premises.

A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read. There were at least 7 days of nonperishable and 2 days of perishable foods. Centrally stored medications were stored in locked cabinets. LPA observed fire extinguisher was fully charged and serviced within the past 12 months. Smoke and Carbon monoxide detectors were operational. Toxic chemicals were stored in a locked closet.

Facility cited with 1 Type A and 2 Type B deficiencies.

ADM will send updated copies of the following to CCL on or before 03/02/2023:

· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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Document Has Been Signed on 02/23/2023 02:44 PM - It Cannot Be Edited


Created By: James Sampair On 02/23/2023 at 02:19 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: 075600618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 knives and scissors in unlocked drawers, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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Cleared during inspection.
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: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/23/2023 02:44 PM - It Cannot Be Edited


Created By: James Sampair On 02/23/2023 at 02:19 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: 075600618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 without records showing that drills were conducted on a quarterly basis, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2023
Plan of Correction
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Licensee will conduct a drill and show proof to LPA. Also, Licensee will implement a process to ensure that they will be conducted during each shift ongoingly.
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

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 3 of the 3 gates, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2023
Plan of Correction
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Add self-closing mechanism to each gate and ensure that they fully latch closed. Inform LPA on or before due date that adjustment has been made.
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: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023


LIC809 (FAS) - (06/04)
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