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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200921
Report Date: 09/07/2022
Date Signed: 09/07/2022 06:15:54 PM

Document Has Been Signed on 09/07/2022 06:15 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:A FAMILY OF CAREFACILITY NUMBER:
079200921
ADMINISTRATOR:TAYLOR, KATHLEENFACILITY TYPE:
740
ADDRESS:1945 ST MARTIN PLACETELEPHONE:
(510) 755-7810
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 7DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Kathleen Taylor, Administrator TIME COMPLETED:
06:35 PM
NARRATIVE
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On 9/7/2022 at 3:30PM, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an infection control inspection. LPA met with Administrator Kathleen Taylor. Facility has census of 7.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. Pool was properly secured and locked. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.

Facility has enough 2-day perishable food and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility has a mitigation plan and updated infection control plan. Facility maintains record of routine screening for residents and staff.

...continued to LIC809C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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 09/07/2022 06:15 PM - It Cannot Be Edited


Created By: Leslie Ibo On 09/07/2022 at 05:33 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: A FAMILY OF CARE
FACILITY NUMBER: 079200921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance. All individuals subject to a criminal record review...prior to working, residing or volunteering in a licensed facility: Obtain a California clearance...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review licensee failed to comply with the above, licensee let S4 started working at the facility without obtaining fingerprint clearances, records review indicated that S4's fingerprint clearance "still in process", which poses an immediate health and safety risk to residents in care.
POC Due Date: 09/07/2022
Plan of Correction
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Administrator sent S4 home. Adminstrator agreed that S4 will have fingerprint cleared before working at the facility.
Civil penalty was assesed during the visit.
Cleared during the 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022


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: A FAMILY OF CARE
FACILITY NUMBER: 079200921
VISIT DATE: 09/07/2022
NARRATIVE
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Facility received an approval for capacity increase of 7 on 4/21/2022. License is being updated on the system.

LPA observed the following:

· S4 started working at the facility without fingerprint clearance, based on records review fingerprint clearance indicated still “in process” .

Civil penalty was assessed during today’s visit.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.


Deficiency, plan and proof of correction and civil penalty were discussed with Kathleen Taylor.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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