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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200760
Report Date: 02/18/2025
Date Signed: 02/18/2025 03:12:49 PM

Document Has Been Signed on 02/18/2025 03:12 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/
DIRECTOR:		LODIA, ROMEOFACILITY TYPE:
740
ADDRESS:2159 SARAH CTTELEPHONE:
(510) 283-5098
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 6CENSUS: 5DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:ROMEO LODIA, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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On 2/18/2025 at 12:55PM, Licensing Program Analyst (LPA) Carol 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 04/13/2025. 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. 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 120 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 01/08/2025. Emergency Disaster Plan was last posted on 03/22/2024. First aid kit was observed to be complete. Fire drill was last conducted on 01/25/2025.

Continued on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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 02/18/2025 03:12 PM - It Cannot Be Edited


Created By: Carol Fowler On 02/18/2025 at 02:42 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: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)

87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication

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. LPA observed unlocked central storage for medications which poses an immediate health risk to persons in care.

POC Due Date: 02/19/2025
Plan of Correction
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Administrator locked medication during the visit. 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: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


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: 02/18/2025
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Continued from LIC809

LPA reviewed three (3) staff records, and all staff have criminal record clearance and holds a current first aid/CPR certificate. four (4) Clients records were reviewed all complete.

DEFICIENCIES OBSERVED DURING VISIT:
At 1:19PM LPA observed medication door was unlocked.

LPA reviewed following documents.

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

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted, a copy of this report and appeals rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC809 (FAS) - (06/04)
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