Community Care Licensing

Document Has Been Signed on 05/03/2023 06:03 PM - It Cannot Be Edited

FACILITY NAME:	ABRAHAM REST HOME		FACILITY NUMBER:	075601018
ADMINISTRATOR:	MARIA LORENZANA		FACILITY TYPE:	740
ADDRESS:	1148 FLOWERWOOD COURT		TELEPHONE:	(925) 977-9743
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY: 6		CENSUS: 5	DATE:	05/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Annette Sanchez		TIME COMPLETED:	06:15 PM

SUPERVISORS NAME: Harpreet Humpal LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023

Link to Parent Document Below:

FACILITY NAME: ABRAHAM REST HOME	FACILITY NUMBER: 075601018
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

Type A

Section Cited

CCR

87303(e)(2)

(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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the kitchen sink that was measured at 138.8 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Licensee shall attest in text or email to LPA on or before due date that the water temperature has been reduced to a safe level.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023

Link to Parent Document Below:

FACILITY NAME: ABRAHAM REST HOME	FACILITY NUMBER: 075601018
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

Type B

Section Cited

CCR

87411(c)(6)

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining staff training documentation in personnel records at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Licensee shall add documentation of completed training to staff files (okay to maintain files in electronic format so long as Licensing staff always have access to that documentation during an inspection. Licensee shall inform LPA on or before the due date that POC has been completed.

Type B

Section Cited

HSC

1569.695(a)(2)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by maintaining an inadequate supply of emergency food and water at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Licensee shall obtain and store in facility and label as Emergency Food and Water an adequate supply of food and water for residents and staff on or before the due date. Licensee shall inform LPA on or before the due date that POC has been completed.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023

Link to Parent Document Below:

FACILITY NAME: ABRAHAM REST HOME	FACILITY NUMBER: 075601018
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

Type B

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 of 2 resident's files that contain no physician's order for a bed rail, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Licensee shall update 2 of 2 resident's files that contain no physician's order for bed railings on or before the due date. Licensee shall inform LPA on or before the due date that POC has been completed.

Type B

Section Cited

CCR

87705(h)

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 of the 2 backyard gates (the side and back gates) that are not self-closing, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Licensee shall add self-closing mechanism to both gates on or before the due date. Licensee shall inform LPA on or before the due date that POC has been completed.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023