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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201047
Report Date: 04/27/2022
Date Signed: 04/27/2022 11:04:59 AM

Document Has Been Signed on 04/27/2022 11:04 AM - 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:AGNES HOUSEFACILITY NUMBER:
079201047
ADMINISTRATOR:BERNARDINO, ALBERTOFACILITY TYPE:
740
ADDRESS:1660 ARKELL RDTELEPHONE:
(925) 818-6536
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Alberto BernardinoTIME COMPLETED:
11:15 AM
NARRATIVE
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On 04/27/2022 at 8:15AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with S1 upon entry, who then called the administrator who arrived at 9:30AM.

Facility has a mitigation plan (LIC 808) in place dated 07/09/2021 to mitigate the spread of COVID-19. LPA discussed the importance of having an updated infection control plan in accordance with PIN 22-13-ASC.

LPA inspected the facility inside and outside. LPA observed the 2 staff assisting 6 of the 6 clients with activities of daily living. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing.

A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read. Centrally stored medications were locked in the cabinets. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were stored in a locked closet inside the garage. Infection control designated leader is the administrator.

Continued on next page LIC 809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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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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: AGNES HOUSE
FACILITY NUMBER: 079201047
VISIT DATE: 04/27/2022
NARRATIVE
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All staff and 6 clients have been fully vaccinated. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the pantry and garage.

Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged.

Smoke and Carbon monoxide detectors were operational. Adequate supplies of PPE were also observed stored on the premises. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/05/2022:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

Facility cited with 1 Type A and 2 Type B deficiencies, both of which were corrected during the visit.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/27/2022 11:04 AM - It Cannot Be Edited


Created By: James Sampair On 04/27/2022 at 10:05 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: AGNES HOUSE
FACILITY NUMBER: 079201047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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, with the hot water temperature measured at 133 degrees Farenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Licensee corrected deficiency during visit by reducing maximum hot water temperature at 118 degrees Farenheit.
Section Cited
Deficient Practice Statement
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2
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/27/2022 11:04 AM - It Cannot Be Edited


Created By: James Sampair On 04/27/2022 at 10:05 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: AGNES HOUSE
FACILITY NUMBER: 079201047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 because the facility does not have at least 30 gallons of water in case of an emergency on hand which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2022
Plan of Correction
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Licensee corrected deficiency during visit by obtaining and storing 30 gallons of water for emergencies on the premises.
Type B
Section Cited
CCR
80088(a)(1)
80088 FIXTURES, FURNITURE, EQUIPMENT AND SUPPLIES
(a) A comfortable temperature for clients shall be maintained at all times.
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

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 the rooms where the temperature was measured to be as low as 66.1 degrees Farenheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Licensee corrected the deficiencyduring the visit and the temperature was measured by the LPA at 68.2 degrees Farenheit at 10:15AM.
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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
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