<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200822
Report Date: 09/02/2021
Date Signed: 09/02/2021 12:32:43 PM

Document Has Been Signed on 09/02/2021 12:32 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:HOME SWEET HOME OF HERCULESFACILITY NUMBER:
079200822
ADMINISTRATOR:DASTGHEIB, ALI SINAFACILITY TYPE:
740
ADDRESS:295 SPARROW DRTELEPHONE:
(510) 245-2948
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 6DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Ali Dastgheib, administratorTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/02/2021 at 9:05 am, Licensing Program Analysts (LPAs) C. Fowler and G. Luk arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Ali Dastgheib and explained the purpose of the visit.

Upon entry, LPA's temperatures were checked by staff. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPAs observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

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

The following deficiencies were observed during the visit:
-At 9:30am, LPAs observed resident had full bed rail and not on hospice care.
-At 9:45am LPAs observed facility did not have one week of non perishable food.
-At 10:00am LPAs observed a lock on the side gate. Administrator stated side gate was locked at night.
-At 11:00am, LPAs observed staff was not finger print cleared.


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 appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 09/02/2021 12:32 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/02/2021 at 11:30 AM
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: HOME SWEET HOME OF HERCULES
FACILITY NUMBER: 079200822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by locking side gate which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
1
2
3
4
Staff removed lock during inspection. Deficiency cleared.

Civil penalty of $500 is being assessed.
Type A
Section Cited
CCR
87412(a)(13)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by having staff that is not finger print cleared working at the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
1
2
3
4
Administrator will obtain finger print clearance for staff and provide documentation to CCLD by POC date.

Civil penalty of $500 is being assessed.
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: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/02/2021 12:32 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/02/2021 at 11:30 AM
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: HOME SWEET HOME OF HERCULES
FACILITY NUMBER: 079200822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having full bed rail for resident who's not on hospice care which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
1
2
3
4
Administrator has agreed to remove full bed rail and provide picture to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/02/2021 12:32 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/02/2021 at 11:30 AM
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: HOME SWEET HOME OF HERCULES
FACILITY NUMBER: 079200822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not having one week of non perishable food which poses a potential health and safety risk to persons in care.
POC Due Date: 09/09/2021
Plan of Correction
1
2
3
4
Administrator has agreed to purchase additional non perishable food supply and submit receipt to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5