<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600407
Report Date: 02/26/2023
Date Signed: 02/26/2023 01:37:29 PM

Document Has Been Signed on 02/26/2023 01:37 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:LAPASA, EDNULFO & REBECCAFACILITY TYPE:
735
ADDRESS:141 GREENMEADOW CIRCLETELEPHONE:
(925) 709-8853
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
02/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Quent Lapasa, CaregiverTIME COMPLETED:
01:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/26/2023 at 09:45AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Quent Lapasa, Caregiver and explained the purpose of the visit. Administrator, Rebecca Lapasa arrived at 10:50AM.

Upon entry, LPA's temperature was checked and LPA did not observe any COVID signs posted on front door. LPA observed screening station that contained hand sanitizer. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 106.5 degrees Fahrenheit.

During record review, LPA observed facility has a copy of the infection control plan on file.

LPA request the following documents to be submitted to CCLD by 3/6/2023.
  • Personnel record (LIC500)
  • Facility Roster (LIC9020)
  • Emergency disaster plan (LIC610D)
  • Designation of Facility Responsibility (LIC308)

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 16
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: 02/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.

The following deficiencies were observed:


  • At 09:45AM, LPA observed S3 was not associated to the facility.
  • At 09:45AM, LPA observed living room full of moving boxes.
  • At 09:50AM, LPA observed cabinet locked with chain and lock. Cabinet contained food.
  • At 09:50AM, LPA observed medication on top of refrigerator.
  • At 11:00AM, LPA observed kitchen refrigerator contained frozen foods, water, and lettuce. Facility has refrigerator in locked staff bedroom.
  • At 11:05AM, LPA observed fire extinguisher did not have receipt or updated tag from the fire department.
  • At 11:10AM, LPA observed 2 mattresses and a dryer on right side of house.
  • At 11:15AM, LPA observed window screen on Master bedroom (staff room) in disrepair.
  • At 11:15AM, LPA observed broken window with tape in bedroom #3
  • At 11:25AM, LPA observed facility did not have supplies of staple nonperishable foods for 7-days and fresh perishable foods for 2-days
  • At 11:35AM, LPA observed that client files were not current.
  • At 11:40AM, LPA observed that four (4) out of the five (5) clients were over the age of 59 and facility did not have an exception.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2023
LIC809 (FAS) - (06/04)
Page: 12 of 16
Document Has Been Signed on 02/26/2023 01:37 PM - It Cannot Be Edited


Created By: Laura Hall On 02/26/2023 at 12:35 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: OAK HILLS RESIDENTIAL FACILITY
FACILITY NUMBER: 075600407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

(2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having S3 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
1
2
3
4
Administrator agreed to submit an LIC9182 and a copy of S3's identification to CCLD by POC date.
Type A
Section Cited
CCR
80075(k)(1)
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:

(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on(observation, the licensee did not comply with the section cited above in having medication inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
1
2
3
4
Administrator locked medication in locked staff bedroom. Deficiency cleared during visit.
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: 02/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2023


LIC809 (FAS) - (06/04)
Page: 13 of 16
Document Has Been Signed on 02/26/2023 01:37 PM - It Cannot Be Edited


Created By: Laura Hall On 02/26/2023 at 12:40 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: OAK HILLS RESIDENTIAL FACILITY
FACILITY NUMBER: 075600407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds

(a) The facility 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having window screen in disrepair, broken bedroom window, boxes in living room, and fire extinguisher not current which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
1
2
3
4
Administrator agreed to purchase or have fire department check fire extinguisher, fix broken window, fix screen, remove all boxes out of living room, and submit a photo to CCLD by POC.
Type B
Section Cited
CCR
80087(b)
80087 Buildings and Grounds

(b) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having dryer and mattress in passageway on right side of house which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
1
2
3
4
Administrator agreed to remove mattress and dryer and submit photo to CCLD by POC date.
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: 02/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2023


LIC809 (FAS) - (06/04)
Page: 14 of 16
Document Has Been Signed on 02/26/2023 01:37 PM - It Cannot Be Edited


Created By: Laura Hall On 02/26/2023 at 12:48 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: OAK HILLS RESIDENTIAL FACILITY
FACILITY NUMBER: 075600407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(1)
85076 Food Service

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having supply of 7-day non perishables and 2-days perishables which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
1
2
3
4
Administrator agreed to purchase food and submit photo of perishables and non perishable to CCLD by POC date.
Type B
Section Cited
CCR
80070(a)
80070 Client Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having clients files current which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
1
2
3
4
Administrator agreed to update all files and submit self-certification that all files have been updated to CCLD by POC date.
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: 02/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2023


LIC809 (FAS) - (06/04)
Page: 15 of 16
Document Has Been Signed on 02/26/2023 01:37 PM - It Cannot Be Edited


Created By: Laura Hall On 02/26/2023 at 12:55 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: OAK HILLS RESIDENTIAL FACILITY
FACILITY NUMBER: 075600407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4

85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on(observation, interview, and record review, the licensee did not comply with the section cited above in requesting an age exception request which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
1
2
3
4
Administrator agreed to submit a request for age exception to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 02/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2023


LIC809 (FAS) - (06/04)
Page: 16 of 16