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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200921
Report Date: 10/24/2024
Date Signed: 10/24/2024 01:27:09 PM

Document Has Been Signed on 10/24/2024 01:27 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:A FAMILY OF CAREFACILITY NUMBER:
079200921
ADMINISTRATOR/
DIRECTOR:		TAYLOR, KATHLEENFACILITY TYPE:
740
ADDRESS:1945 ST MARTIN PLACETELEPHONE:
(510) 755-7810
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 7DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:11 AM
MET WITH:Carla Page, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 10/24/2024 at 10:11AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Carla Page and explained the purpose of the visit. The Administrator currently holds a certificate (#7016298740) in pending status per CCLD Portal. The facility’s fire clearance was approved for three (3) ambulatory and four (4) non ambulatory residents.

LPA toured the facility with Caregiver, Carla Page including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms, One (1) occupied by staff and four (4) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA observe a pool behind a properly secured locked gate in the backyard. A comfortable temperature is maintained at 81 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 118.7 degrees Fahrenheit. Residents' bathrooms are equipped with grab bars and nonskid mats. 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 purchased on 10/19/2024. Emergency Disaster Plan was last posted on 11/09/2023. First aid kit was observed to be complete. No fire drill conducted with residents as of today.


Continued LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: A FAMILY OF CARE
FACILITY NUMBER: 079200921
VISIT DATE: 10/24/2024
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Continued from LIC809.

LPA reviewed five (5) resident records and five (54) staff records during visit

The following forms to be updated and submitted to CCLD by 10/31/2024:

· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC610E Emergency Disaster Plan
· LIC308 Designation of facility responsibility

LPA observed the following deficiency:

· At 10:55AM LPA observed the following items in laundry room in an unlocked cabinet: Cutter& Repel Sportsman- Insect Repellent, Swan- Rubbing Alcohol and Marquee- Hydrogen Peroxide

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided to Carla Page

Continued LIC809D

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2024 01:27 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 10/24/2024 at 01:02 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: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in having Cutter& Repel Sportsman- Insect Repellent, Swan- Rubbing Alcohol and Marquee- Hydrogen Peroxide in an unlocked cabinet inside laundry room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Caregiver immediately removed items and placed in a locked cabinet. 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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