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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600407
Report Date: 03/30/2023
Date Signed: 03/30/2023 11:39:21 AM

Document Has Been Signed on 03/30/2023 11:39 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: 4DATE:
03/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Rebecca Lapasa, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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On 3/30/2023 at 10:50AM, Licensing Program Analysts (LPAs) L. Hall and C. Fowler arrived unannounced to conduct case management visit. LPA met with Rebecca Lapasa, Administrator, and explained the purpose of the visit.

While LPAs were conducting a Plan of Correction (POC) visit on today's date, LPAs were informed that C1 was sent to the hospital on 3/15/2023 and is now in a skilled nursing facility. LPA L. Hall did not receive an incident report that C1 was transported to a hospital.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency 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: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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 03/30/2023 11:39 AM - It Cannot Be Edited


Created By: Laura Hall On 03/30/2023 at 10:56 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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2023
Section Cited
CCR
80061(b)

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80061 (b) ...during the operation of the facility, of any of the events... a report shall be made to the licensing agency... within seven days following the occurrence... Requirements was not met as evidence by:
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Administrator agreed to submit an incident report LIC624 to CCLD for C1 by POC date.
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Based on LPA's observation and interview the Licensee did not comply with the section cited above in reporting an incident for C1 to CCLD, which poses a potential risk to the health and safety 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: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
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