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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200135
Report Date: 06/27/2024
Date Signed: 06/27/2024 05:15:11 PM

Document Has Been Signed on 06/27/2024 05:15 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:ARC OF THE EAST BAY WALPERT AVP PROGRAM, THEFACILITY NUMBER:
019200135
ADMINISTRATOR/
DIRECTOR:		TUTTLE, RENEEFACILITY TYPE:
775
ADDRESS:1101 WALPERT STREETTELEPHONE:
(510) 357-3569
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 200CENSUS: 79DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Renee Tuttle/Program DirectorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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At 12:00 noon on this day, June 27, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Program Director (PD) Renee Tuttle, and informed the reason for visit.

Facility has Infection Control Plan that was submitted by Director of Operation Joanne Rolle which was received by LPA on June 23, 2022.

LPA toured the facility inside out with PD. LPA inspected building #s 1, 2, 3 (Jane building), 4 (Larc Hall) and 5 (front office building), building # 1111, common areas and kitchen in building # 4. All buildings except Larc Hall and front office have quiet rooms. Building #1111 is for management/administration use. Facility has adequate supplies of snacks and activity materials. First aid kits inspected and observed complete with manual. Storages for cleaning supplies were observed locked.

All buildings have fire extinguishers which LPA observed fully charge; the extinguisher in the front building showed serviced October 4, 2023. Hot water temperature in one of the bathrooms in building # 3 was tested, and measured at 107.5 degrees Fahrenheit. Facility conducts disaster drills and records showed last conducted May 13 and 22, 2024. Facility has smoke and carbon monoxide detectors that were tested and observed in operating condition. Facility does not handle clients money.

LPA reviewed 5 staff and 7 residents files, and interviewed 2 staff and 2 clients.


.....continued of 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ARC OF THE EAST BAY WALPERT AVP PROGRAM, THE
FACILITY NUMBER: 019200135
VISIT DATE: 06/27/2024
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Page 2

LPA observed the following:
-at 12:20 p.m., chipped/worn out laminate flooring in building # 3 (Jane building)
-at 3:40 p.m., client (C2) has no admission appraisal or appraisal/needs and services plan on file.

LPA received copies of the following updated/current documents on this same day.
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)

Deficiencies are cited in violation of Title 22 California Code of Regulations and listed on 809Ds. Failuree to submit proof of corrections (POCs) along with the LIC9098 Proof of Correction form by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with Renee Tuttle.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2024 05:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/27/2024 at 04:43 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: ARC OF THE EAST BAY WALPERT AVP PROGRAM, THE
FACILITY NUMBER: 019200135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 chipped/worn out laminate flooring in building # 3 (Jane building) which poses a personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Program Director to have the flooring replaced and submit proof by 7/25/24.
Type B
Section Cited
CCR
85068.1(b)
85068.1 Admission Procedures
(b) No client may be admitted prior to a determination of the facility's ability to meet the needs of the client, which must include an appraisal of his/her individual service needs as specified in Sections 80068.2 and 85068.2.


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 client (C2) not having admission appraisal and/or appraisal/neeeds and service plan on file which poses a potential health, safety and/or personal rights risks to person in care.
POC Due Date: 07/11/2024
Plan of Correction
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PD to complete the document and submit proof by 7/11/24.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
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