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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601492
Report Date: 10/29/2021
Date Signed: 11/03/2021 11:52:06 AM

Document Has Been Signed on 11/03/2021 11:52 AM - 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:JONED'S REST HOME IIFACILITY NUMBER:
075601492
ADMINISTRATOR:BASBAS, EDGARDO G.FACILITY TYPE:
740
ADDRESS:141 VIA MONTETELEPHONE:
(925) 323-4463
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 4DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Julieta BasbasTIME COMPLETED:
02:31 PM
NARRATIVE
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection of the facility. Upon entry into the facility, LPA observed that 3 of 3 staff members were wearing facial covering. They followed all of the required steps necessary for visitors to control infections including asking for his vaccination status and the use of a screening station near the entrance. COVID-19 signs were posted in common areas to promote hand washing and physical distancing and staff document temperature and health status of staff and residents on a daily basis. The LPA explained the purpose of the visit with Licensee and designated Infection control leader Julieta Basbas, who toured the inside and outside with the LPA.

Ms. Basbas reported that all staff and residents were fully vaccinated. The LPA observed that the temperature within the facility was maintained at a comfortable temperature, as was the hot water that was at 110 degrees Fahrenheit. There were sufficient food and water supplies, which were appropriately labelled. The Smoke and Carbon monoxide detectors were fully operational. and the fire extinguishers were fully charged and last replaced May of 2021.

The facility was cited for 2 Type B deficiencies, the details of which are in the LIC809-D:
  • Physical Plant/Environmental Safety - Type B: 87303(a) - broken hand railing on deck, both gates at front of facility are broken, shed door is broken, broken equipment and other refuse in backyard.
  • Disaster Preparedness - Type B: 1569.695(a)(2) - existing disaster and emergency plan lacking specific procedures for this facility and a lack of 72 hours of emergency food and water at the facility.

Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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 2
Document Has Been Signed on 11/03/2021 11:52 AM - It Cannot Be Edited


Created By: James Sampair On 10/29/2021 at 12:28 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: JONED'S REST HOME II
FACILITY NUMBER: 075601492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2021

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 due to: a broken hand railing on deck, both gates at front of facility are broken, shed door is broken, broken equipment and other refuse in backyard, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2021
Plan of Correction
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Send proof to LPA that the following repairs have been completed: deck hand railing, "Do Not Use" or similar sign for the gate nailed in place, add standard latch to other gate, replace shed door, and remove broken equipment and refuse from backyard
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(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
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Based on interview and record review, the licensee did not comply with the section cited above because the existing disaster and emergency plan lacks specific procedures for this facility. Further, enough emergency food and water for staff and residents for 72 hours is not on the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2021
Plan of Correction
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Create and send to LPA a copy of a disaster and emergency response plan specifically for this facility, which fully addresses all requirements for the facility to be self-reliant including, but not limited to, a short-term or long-term power failure. Additionally, show proof that emergency food and water for at least 8 people (staff and residents) is stored on the facility grounds and stored separately from the food and water used on a day-to-day basis.
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: 10/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2021


LIC809 (FAS) - (06/04)
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