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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200810
Report Date: 06/17/2021
Date Signed: 06/17/2021 01:07:02 PM

Document Has Been Signed on 06/17/2021 01:07 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:GEN CARE MANORFACILITY NUMBER:
079200810
ADMINISTRATOR:ARATAN, GENNY FIEFACILITY TYPE:
740
ADDRESS:5707 OSAGE PLACETELEPHONE:
(925) 889-9967
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 4CENSUS: 4DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Rizza Madlangbayan, AdministratorTIME COMPLETED:
01:10 PM
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On 06/17/21 at 11:15 AM, Licensing Program Analyst (LPA) conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 5 staff wearing face masks during visit.

LPA observed one central entry point designated for universal entry screening at the main entrance. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Per staff, the designated infection control leader is the head nurse. LPA observed COVID-19 signages in common areas. Facility has a completed mitigation plan in place dated 12/26/20 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with staff as well as COVID-19 infection control practices. LPA inspected the facility inside and outside.

LPA observed locked medication inside the kitchen closet. Toxic chemicals were observed stored in locked garage cabinets and inside the laundry area. Adequate PPE supplies were observed in a garage cabinets. All staff and residents have been fully vaccinated since February 4, 2021.

Continued on next page LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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: GEN CARE MANOR
FACILITY NUMBER: 079200810
VISIT DATE: 06/17/2021
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There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 70 degrees Fahrenheit. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational. A written Emergency/Disaster plan dated 02/26/21 was observed posted in the hallway bulletin board. Sharp objects were locked in the kitchen cabinet.

Updated copies of the following documents were given by administrator to LPA during visit:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
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