<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601497
Report Date: 08/17/2022
Date Signed: 08/17/2022 06:25:27 PM

Document Has Been Signed on 08/17/2022 06:25 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:AARON'S ADVANCE CARE HOME INC.FACILITY NUMBER:
075601497
ADMINISTRATOR:QUIAMBAO, ROSA ELMAFACILITY TYPE:
740
ADDRESS:122 LOS ALTOS AVENUETELEPHONE:
(925) 954-5329
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 4DATE:
08/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jovita Aduca and by phone Rosa QuiamboaTIME COMPLETED:
06:45 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 8/17/22 at 4:00 PM, Licensing Program Analyst (LPA) J. Sampair conducted a case management visit concerning a lack of an exception having been granted for R1 due to their gastrostomy tube, which is a prohibited health condition (Title 22 Section 87615(a)(2). Upon entry, LPA explained the purpose of the visit to staff member Jovita "Jovi" Aduca. However, the LPA instead needed to speak to the licensee, Rosa Quiambao, because of Ms. Aduca's limited English proficiency. For that reason, the LPA interviewed the licensee and administrator, Rosa Quiamboa, about the deficiency over the phone.

Ms. Quiamboa confirmed that an exception had never been granted for R1's prohibited health condition, for which the facility was cited with a Type B deficiency (refer to LIC 809-D).

Exit interview conducted with Licensee. A copy of this report and appeal rights provided via email..
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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 08/17/2022 06:25 PM - It Cannot Be Edited


Created By: James Sampair On 08/17/2022 at 05:18 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: AARON'S ADVANCE CARE HOME INC.
FACILITY NUMBER: 075601497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2022
Section Cited
CCR
87616(a)

1
2
3
4
5
6
7
87616 EXCEPTIONS FOR HEALTH CONDITIONS (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited . . . health condition but believes that the intent of the law can be met through alternative means.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
By the due date, the licensee shall submit to the LPA a written exemption request that includes, but is not limited to:
(1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition.
8
9
10
11
12
13
14
Based on interview and record review, the licensee submitted a written request for an exception without having it granted by the Department, which poses a potential health risk to residents in care.
8
9
10
11
12
13
14
(2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility.
(3) Plan for minimizing the impact on other residents.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2