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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600407
Report Date: 12/24/2021
Date Signed: 12/24/2021 10:45:05 AM

Document Has Been Signed on 12/24/2021 10:45 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:OAK HILLS RESIDENTIAL FACILITYFACILITY NUMBER:
075600407
ADMINISTRATOR:LAPASA, EDNULFO & REBECCAFACILITY TYPE:
735
ADDRESS:141 GREENMEADOW CIRCLETELEPHONE:
(925) 709-8853
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
12/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Adelina DanielesTIME COMPLETED:
11:20 AM
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On 12/24/2021, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Adelina Danieles . LPA called Administrator and left voicemail; per Adelina D. the administrator is not available. LPA called Administrator 5x but could not leave a voicemail, LPA also sent a text Administrator but no response. LPA observed 5 clients during the visit. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 72 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.


Continued on next page LIC 809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/24/2021
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: OAK HILLS RESIDENTIAL FACILITY
FACILITY NUMBER: 075600407
VISIT DATE: 12/24/2021
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LPA observed the following:
· Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use.

· Facility DO NOT have adequate 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles).

· Routine symptom screening (+/- temperature and symptom check) has NOT been initiated at entry for all staff, residents, and visitors.

· Facility does NOT documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents.

· A sign-in policy has NOT been enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).

· Signs has NOT been posted at facility entrance with updates to visitor policy.

· Hand washing and/or hand sanitizer was NOT on entry is requested for all staff, residents, and visitors.

· Licensee has NOT provided all staff who are working with fit testing for N95 respirators.

· Facility has NOT developed policies for screening residents after they return from an outing.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.



Deficiencies and plan and proof of corrections were discussed with Adelina Danieles.
Exit interview conducted and a copy of this report provided.

*Note: LPA spoke with Administrator at around 10:25AM and read the report.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2021
LIC809 (FAS) - (06/04)
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