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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200760
Report Date: 04/20/2023
Date Signed: 04/20/2023 04:09:19 PM

Document Has Been Signed on 04/20/2023 04:09 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:PREMIERE HOME CAREFACILITY NUMBER:
079200760
ADMINISTRATOR:LODIA, ROMEOFACILITY TYPE:
740
ADDRESS:2159 SARAH CTTELEPHONE:
(510) 283-5098
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 6CENSUS: 4DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Romeo Lodia, AdministratorTIME COMPLETED:
04:40 PM
NARRATIVE
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On 4/20/2023 at 12:00PM, Licensing Program Analyst (LPA) C. Fowler conducted an unannounced 1-Year Required inspection. LPA met with Administrator, Romeo Lodia and explained the purpose of the visit. The Administrator currently holds a certificate (#6034539740) that expired on 04/13/2023, Administrator has submitted forms and training's for renewal on 01/26/2023 and is waiting for license. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four (4) total bedrooms which three (3) bedrooms are occupied by residents, one (1) vacant and one (1) staff quarters on the grounds. There are three (2) full bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars. Hot water temperature in the shared clients’ bathroom was measured at 117.9 degrees Fahrenheit. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/25/2023. Emergency Disaster Plan was last posted on 04/18/2023. First aid kit was observed to be complete. Fire drill was last conducted on 04/04/2023.

Continued on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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: PREMIERE HOME CARE
FACILITY NUMBER: 079200760
VISIT DATE: 04/20/2023
NARRATIVE
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Three (3) staff records were reviewed, and all staff have criminal record clearance and holds a current first aid certificate. All five (5) Clients records were reviewed.

LPA observed the following deficiencies:
  • At 1:13PM, LPA observed Glade bathroom spray, Zep hardwood floor cleaner, and Lysol located under the bathroom sink.

LPA requested the following documents to be submitted to CCLD by 04/27/2023.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

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 conducted. A copy of appeal rights and this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2023 04:09 PM - It Cannot Be Edited


Created By: Carol Fowler On 04/20/2023 at 03:55 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: PREMIERE HOME CARE
FACILITY NUMBER: 079200760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having cleaning solutions such as Glade bathroom spray, Zep hardwood floor cleaner, and Lysol located under the bathroom sinkwhich poses an immediate health, safety risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Administrator locked the cleaning solutions Glade bathroom spray, Zep hardwood floor cleaner, and Lysol in the laundry room cabinet. deficiency cleared during visit.
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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


LIC809 (FAS) - (06/04)
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