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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600407
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:08:27 PM

Document Has Been Signed on 08/08/2024 12:08 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:OAK HILLS RESIDENTIAL FACILITYFACILITY NUMBER:
075600407
ADMINISTRATOR/
DIRECTOR:		LAPASA, EDNULFO & REBECCAFACILITY TYPE:
735
ADDRESS:141 GREENMEADOW CIRCLETELEPHONE:
(925) 709-8853
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 3DATE:
08/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Quent Lapasa, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 8/8/2024 at 10:45am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced POC visit that was conducted on 7/30/2024, regarding administrator qualifications and certification. LPA met with Quent Lapasa, caregiver. Administrator, Rebecca Lapasa, arrived at 11:35am and explained the purpose of the visit.

S2 forwarded an email from the Administrator certificate department dated 8/7/2024, showing they received the recertification March 2023, and will be contacting the Licensee. LPA allotted a week extension, which will be 8/15/2024, to implement a plan.

During visit LPA observed a visitor, which was one of the C1 relatives. LPA was then informed C1 was hospitalized and then transferred to a skilled nursing facility. The Administrator/Licensee did not report the incident CCLD.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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 08/08/2024 12:08 PM - It Cannot Be Edited


Created By: Laura Hall On 08/08/2024 at 11:21 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: OAK HILLS RESIDENTIAL FACILITY
FACILITY NUMBER: 075600407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2024
Section Cited
CCR
80061(b)

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80061 (b) Upon the occurrence, during the operation of the facility... (1) a report shall be made to the licensing agency within the agency's next working day during its normal business hours... (2) ...shall be submitted to the licensing agency within seven days following the occurrence... This requirement was not met as evidence by:
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licensee/Administrator agreed to submit the incident report for C1 to CCLD by POC date.
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Based on interview and observation, the Licensee did not comply with the section cited above in reporting an incident to CCLD for C!, which poses a potential health and safety risk to persons in care.
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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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
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