075601459-4-18-2023-15-AS-LHAL-CR22SS-20230418173937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601459
Report Date: 04/18/2023
Date Signed: 04/18/2023 05:39:47 PM

Document Has Been Signed on 04/18/2023 05:39 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:	BALTIC SEA MANOR		FACILITY NUMBER:	075601459
ADMINISTRATOR:	PRICE, VIVIAN		FACILITY TYPE:	740
ADDRESS:	311 BALTIC SEA COURT		TELEPHONE:	(925) 783-0988
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY: 6		CENSUS: 5	DATE:	04/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Florin Jervoso, Direct Support Professional		TIME COMPLETED:	05:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/18/2023 at 3:05PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Direct Support Professional, Florin Jervoso and explained the purpose of the visit. The Administrator currently holds a certificate (#6017788740) that expires on 06/19/2024. The facility’s fire clearance was approved for six (6) non-ambulatory and 1 bedridden resident. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms, which three (3) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 70 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 104.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors/ carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 04/04/2022. Emergency Disaster Plan was last posted on 5/16/2022. First aid kit was observed to be complete. Fire drill was last conducted on 05/16/2022. Continued on LIC809.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BALTIC SEA MANOR	FACILITY NUMBER: 075601459
	VISIT DATE: 04/18/2023

NARRATIVE

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Continued from LIC809.

Three (3) staff records were reviewed, and all staff have criminal record clearance and holds a current first aid and CPR certificate. All five (5) Clients records were reviewed.

LPA observed the following deficiencies:

At 4:10PM, LPA observed appraisal needs and service plan for all residents were not current.

LPA requested the following documents to be submitted to CCLD by 4/25/2023.

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

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted. A copy of appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/18/2023 05:39 PM - It Cannot Be Edited

Created By: Laura Hall On 04/18/2023 at 05:24 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: BALTIC SEA MANOR	FACILITY NUMBER: 075601459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to make all residents appraisal needs and service plans current and submit a self-certification that it has been complete to CCLD by POC date.

Section Cited


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

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:

Laura Hall

LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC809 (FAS) - (06/04)

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