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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601228
Report Date: 05/05/2022
Date Signed: 05/05/2022 12:06:14 PM

Document Has Been Signed on 05/05/2022 12:06 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:KC CARE HOMEFACILITY NUMBER:
075601228
ADMINISTRATOR:LEGASPI, EVELYN & OSCARFACILITY TYPE:
740
ADDRESS:1866 CLAYTON WAYTELEPHONE:
(925) 451-1803
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 6CENSUS: 6DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Oscar Legaspi, AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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On 05/05/2022 at 11:02 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Administrator Oscar Legaspi and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 05/27/2021.

The following deficiency was observed during the visit:


LPA observed medication in the refrigerator accessible to the residents.
LPA observed a knife in the kitchen left accessible and chemicals in the laundry room left unlocked.

The Facility was cited and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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 2
Document Has Been Signed on 05/05/2022 12:06 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 05/05/2022 at 11:55 AM
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: KC CARE HOME
FACILITY NUMBER: 075601228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 by having chemicals in the laundry room unlocked and a knife accessible which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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The facility will lock up the chemicals and knife. In addition by 5/19/2022, facility will provide staff training with chemical handling and storage. Facility will submit documentation to CCLD with date of training, signature of attendees, and copy training materials.
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 by having medication in the fridge accessible to clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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The facility will lock up medications. In addition by 5/19/2022, facility will provide medication training for all staff that administer medication. A documentation of training will be sent to CCLD by POC date.
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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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