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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201264
Report Date: 07/12/2024
Date Signed: 07/12/2024 12:06:35 PM

Document Has Been Signed on 07/12/2024 12:06 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:HOUSE OF JOSEPH CARE HOMEFACILITY NUMBER:
079201264
ADMINISTRATOR/
DIRECTOR:		MENDOZA, LIWAYWAYFACILITY TYPE:
740
ADDRESS:4262 ROSEWOOD DRTELEPHONE:
(925) 378-9906
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 5DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator, Liwayway Mendoza TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 7/12/2024 at 10:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver/ House Manager, Gretchen "Cheche" Recto and explained the purpose of the visit. Administrator, Liwayway Mendoza arrived at 11:45AM. The facility’s fire clearance was approved for 6 non-ambulatory.

LPA toured facility with House Manager including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 5 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 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 113.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 6/10/2024. Emergency Disaster Plan was not posted. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/3/2024.

At 10:30 AM, LPA reviewed 5 residents records. At 11:00 AM, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. At 11:20 AM, LPA reviewed a sample of resident’s medications.

Report continues on LIC809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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: HOUSE OF JOSEPH CARE HOME
FACILITY NUMBER: 079201264
VISIT DATE: 07/12/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 10:30am during resident file review LPA observed R2, R3, R4, and R5 to have incomplete files. Each file was missing a different required document. Documents missing were admissions agreement, emergency ID, personal rights, and emergency medical consent forms.
  • At 11:15am during file review LPA observed that facility does not have an updated emergency disaster plan available.




The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/12/2024 12:06 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/12/2024 at 11:56 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: HOUSE OF JOSEPH CARE HOME
FACILITY NUMBER: 079201264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

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 in 4 out of 5 residents files being incomplete which poses a potential personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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By POC date Administrator agrees to review and update files and notify CCLD
Type B
Section Cited
HSC
1569.695(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not having a disaster plan ready and posted which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Administrator printed out a new plan and posted it. Deficiency Cleared.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
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