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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601557
Report Date: 09/20/2022
Date Signed: 09/20/2022 04:47:30 PM

Document Has Been Signed on 09/20/2022 04:47 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:ABRAHAM REST HOMEFACILITY NUMBER:
075601557
ADMINISTRATOR:ABRAHAM, SARAFACILITY TYPE:
740
ADDRESS:1035 BRIGHTWOOD COURTTELEPHONE:
(925) 286-3576
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Annette Sanchez and Alex SanchezTIME COMPLETED:
05:15 PM
NARRATIVE
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On 9/20/22 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit to staff and conducted the initial inspection of the facility with staff member. Administrators Annette Sanchez and Alex Sanchez arrived later and together they toured the facility and discussed facility operations and any deficiencies identified during the inspection.

Facility has an infection control plan in place that they are following. The administrators are the designated infection control leaders. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. Facility had signs posted to promote hand washing and mask wearing.

The fire extinguisher has been serviced within the past 12 months, and the carbon monoxide and smoke detectors were fully functional. The temperature inside of the facility and the hot water were in the safe temperature range. An administrator is on site at least the required 20 hour minimum each week to oversee business operations.

Facility cited for 1 Type B deficiency due to non-regulation medicine dispensing practices (refer to LIC 809-D).

Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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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Document Has Been Signed on 09/20/2022 04:47 PM - It Cannot Be Edited


Created By: James Sampair On 09/20/2022 at 04:23 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: ABRAHAM REST HOME
FACILITY NUMBER: 075601557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 in 6 of the 6 resident's medications with the use of transfer containers to dispense them to the residents on a daily basis, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2022
Plan of Correction
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Licensee must remove the transfer containers, update the plan of operation, and retrain staff to dispense the medications to residents directly from the originally received containers at time of dispensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022


LIC809 (FAS) - (06/04)
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