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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 09/30/2024
Date Signed: 09/30/2024 04:11:33 PM


Document Has Been Signed on 09/30/2024 04:11 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:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR:RAMIREZ, MARGARET DIVINEFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:46CENSUS: 37DATE:
09/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Harmony Venturelli, Executive DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
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On 9/30/2024 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management Inspection in regards to the incident report that was received on 8/29/2024. LPA met with Executive Director, Harmony Venturelli and explained the reason for the visit.

Based on the incident report received on 8/29/2024, resident (R1) was found by a neighbor down the street and was brought back to the facility by police.

During visit, LPA reviewed R1's file including physician's report, care notes, care plan, and incident report. R1's physician's report and care plan indicated that R1 has a history of wandering behaviors and R1 cannot leave the facility unassisted. Interview with staff revealed that when delayed egress alarm went off, S2 went outside and didn't see any residents outside. When a head count was conducted, R1 was found to be missing.


The deficiency was observed (see LIC 809D) and cited from the Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024
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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Document Has Been Signed on 09/30/2024 04:11 PM - It Cannot Be Edited

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: SUNOL CREEK MEMORY CARE
FACILITY NUMBER: 019200484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
HSC
1569.312(a)

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Basic services requirements. Every facility required to...provide at least the following basic services...Care and supervision...
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Executive Director (ED) has already conduct training on elopement and will submit staff sign in sheet to CCLD by POC date.
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This requirement is not met as evidence by: Based on interviews and record reviews, licensee did not comply with the section cited above by R1 wandered off the facility without staff knowledge which poses a potential health and safety risk to the persons in care.
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ED has agreed to re-evaluate R1's care plan and submit new care plan to CCLD by POC date.

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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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