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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600407
Report Date: 04/12/2023
Date Signed: 04/12/2023 12:50:55 PM

Document Has Been Signed on 04/12/2023 12:50 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: 4DATE:
04/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Rebecca Lapasa, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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On 4/12/2023 at 12:05PM Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Rebecca Lapasa, Administrator.

While LPA L. Hall was conducting a complaint investigation (15-AS-20230405110437) on 4/12/2023, during interview with staff and review of complaint documents LPA observed C1 was hospitalized on 3/30/2023. Staff did not report or submit an incident report to CCLD stating the information.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency and/or repeat deficiency in a 12-month period 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: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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 2
Document Has Been Signed on 04/12/2023 12:50 PM - It Cannot Be Edited


Created By: Laura Hall On 04/12/2023 at 12:18 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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2023
Section Cited
CCR
80061(b)

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80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
This requirement was not met as evidence by:
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Administrator submitted incident report to LPA during visit. Deficiency cleared during visit.
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Based upon LPA's observation and record review, Licensee did not comply with the section cited above, in submitting an incident report for an unusual incident, 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: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023


LIC809 (FAS) - (06/04)
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