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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200822
Report Date: 07/10/2024
Date Signed: 07/10/2024 05:43:16 PM

Document Has Been Signed on 07/10/2024 05:43 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/
DIRECTOR:		DASTGHEIB, ALI SINAFACILITY TYPE:
740
ADDRESS:295 SPARROW DRTELEPHONE:
(510) 245-2948
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 4DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:ELIZABETH ZAMORA, CAREGIVERTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-year required visit on 7/10/2024 at 2:15pm. LPA met and toured with Caregiver, Elizabeth Zamora. LPA spoke with Administrator, Ali Dastgheib over the phone. The Administrator currently holds a certificate (#6046284740) that expires on 1/24/2025. The facility’s fire clearance was approved for 5 non-ambulatory and 1 bedridden.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 110.2 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were not in operating condition during visit. Fire extinguisher was last serviced on 6/30/2023. Emergency Disaster Plan was last posted on 07/12/2021. First aid kit was observed to be complete.

LPA reviewed 3 staff record files. 3 of 3 staff files were incomplete . LPA reviewed 4 clients' files and were found to be incomplete.

Report continues on 809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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 07/10/2024 05:43 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/10/2024 at 04:29 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: HOME SWEET HOME OF HERCULES
FACILITY NUMBER: 079200822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in not having carbon monoxide detector/smoke detector working which poses a potential health and safety risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Administrator agreed to check carbon monoxide detector/smoke detector every 6 months to insure detector is in operating condition at all times. DEFICIENCY CLEARED DURING VISIT.
Type B
Section Cited
CCR
87412(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not having the Administrator file located at the facility and having incomplete staff files which poses a potential health and safety risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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2
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4
Administrator agreed to create a file for the Administrator and complete files for S1 and S2, read the regulation and self certify that he will comply with the regulation and submit self certification to the department by the POC date.
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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 07/10/2024 05:43 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/10/2024 at 04:29 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: HOME SWEET HOME OF HERCULES
FACILITY NUMBER: 079200822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above by not having updated Physicians reports for all 4 clients which poses a potential health and safety risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Administrator agreed to get all 4 residents updated Physicians reports updated, and submit copies to the department by the POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not conducting emergency disaster drills which poses a potential health and safety risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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Administrator agreed to conduct an emergency disaster drill and submit log to the department by the POC date.
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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


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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: HOME SWEET HOME OF HERCULES
FACILITY NUMBER: 079200822
VISIT DATE: 07/10/2024
NARRATIVE
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CONTINUE FROM LIC 809

LPAs observed the following deficiencies:
- at 3:10 PM. LPA observed fire extinguisher expired (6/30/2023).
- at 3:20 PM. LPA observed smoke detector/carbon monoxide was not working.
- at 3:40 PM. LPA observed there is no Administrator file located at the facility.
- at 3:50 PM. LPA observed 2 of 3 staff files incomplete.
- at 4:20 PM, LPA observed there is no record of the last fire drill conducted.


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.

The following forms to be updated and submitted to CCL by 07/19/2024:

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


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

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2024 05:43 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/10/2024 at 05:13 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: HOME SWEET HOME OF HERCULES
FACILITY NUMBER: 079200822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, the licensee did not comply with the section cited above by not having the fire extinguisher serviced by the expiration date which poses a potential health and safety risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Administrator agreed to have fire extinguisher serviced and submit a copy of the fire extinguisher tag to the department by the POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
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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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


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