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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601569
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:11:21 PM

Document Has Been Signed on 06/23/2021 04:11 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 IIFACILITY NUMBER:
075601569
ADMINISTRATOR:PRICE, VIVIANFACILITY TYPE:
740
ADDRESS:2237 LYNBROOK DRIVETELEPHONE:
(925) 783-0988
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 AM
MET WITH:Vivian Price, AdministratorTIME COMPLETED:
04:20 PM
NARRATIVE
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On 06/23/2021 at 2:00PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA Vivian Price, Administrator,, and LPA explained the purpose of the visit.

Upon entry, LPA's temperature was not checked. LPA observed hand sanitizer and COVID-19 posters at screening station. LPA toured facility including but not limited to common areas, bathroom, bedrooms, and kitchen, and backyard All hand washing stations were equipped with soap, paper towel, and garbage cans with a lid.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

The following deficiencies were observed during the visit

-On 6/23/2021 at 9:45AM, LPA observed construction being conducted on garage, master bathroom and bedroom #3.
-On 6/23/2021 at 9:45AM, LPA observed staff member not wearing mask.
-On 6/23/2021 at 10:00AM, LPA observed resident residing in living room.
-On 6/23/2021 at 10:10AM, LPA observed a bed in dining room for staff

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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 II
FACILITY NUMBER: 075601569
VISIT DATE: 06/23/2021
NARRATIVE
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Continued from LIC809.

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

Exit interview was conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/23/2021 04:11 PM - It Cannot Be Edited


Created By: Laura Hall On 06/23/2021 at 02:36 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 II
FACILITY NUMBER: 075601569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87208(a)(7)
87208(a)(7) plan of operations. a) Each facility shall have and maintain a current, written definitive plan of operation. ...Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval... (7) sketches, showing dimensions, of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in motifying CCLD regardiing facility construction, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2021
Plan of Correction
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LIcensee/Administrator agreed to submit city permit for construction and new facility sketch to CCLD by POC date.

An immediate civil penalty of $500 is being issued on this date.
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2021 04:11 PM - It Cannot Be Edited


Created By: Laura Hall On 06/23/2021 at 03:34 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 II
FACILITY NUMBER: 075601569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
87307 Personal Accomendations and Services ( a)Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Residents bedrooms shall be provided which meet, at a minimum,.. (B)No room comonly used for other puirposes shall be used as a sleeping room for any , resident... 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 a resident and staff is residing in a common living area which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2021
Plan of Correction
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LIcensee agreed to move resident and staff into an actual bedroom, and submit a photo of the bedrooms completely furnished to CCLD by POC date.
Type B
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in all facilities.(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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 the staff was not wearing masks, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2021
Plan of Correction
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Licensee agreed to remind and train all the staff the importance of wearing mask while working at the facility. This citation was corrected during the visit.
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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
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