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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200629
Report Date: 07/28/2022
Date Signed: 07/28/2022 04:46:06 PM

Document Has Been Signed on 07/28/2022 04:46 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:BAYBERRY HOMEFACILITY NUMBER:
079200629
ADMINISTRATOR:FROILAN ABESAMISFACILITY TYPE:
740
ADDRESS:3526 BAYBERRY DRIVETELEPHONE:
(925) 279-1132
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 4CENSUS: 4DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:FROILAN ABESAMISTIME COMPLETED:
05:00 PM
NARRATIVE
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On 07/28/22 at 3:00PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry into facility, LPA explained the purpose of the visit to staff. LPA met with and toured the facility with Administrator FROILAN ABESAMIS,

Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. 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. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing.

A written Emergency/Disaster plan was posted. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 79.9 degrees and in the safe range. However, the hot water was only 100 degrees, which was below the minimum of 105, for which the facility was cited. Toxic chemicals and sharp objects were stored in locked closets and cabinets. Carbon monoxide and smoke detectors were fully functional and the fire extinguisher was refilled March 2022 and was fully charged. An administrator is on site a minimum of 20 hours a week to oversee proper business operation.

Continued on next page LIC 809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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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: BAYBERRY HOME
FACILITY NUMBER: 079200629
VISIT DATE: 07/28/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 08/05/22:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

Facility cited with one (1) deficiency during this visit.

Exit interview conducted and a copy of this report provided via email.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2022 04:46 PM - It Cannot Be Edited


Created By: James Sampair On 07/28/2022 at 04:28 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: BAYBERRY HOME
FACILITY NUMBER: 079200629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 since the hot water temperature was 100 degrees F.when measured in the kitchen sink which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Administrator will increase the water temperature up to the safe range of 105 to 120 degrees F and send a message to LPA attesting to that fact by the POC due 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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


LIC809 (FAS) - (06/04)
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