075600578-4-21-2023-15-AS-PWAN-CR4TH8-20230421144418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600578
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:44:36 PM

Document Has Been Signed on 04/21/2023 02:44 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	CONCORD ROYALE		FACILITY NUMBER:	075600578
ADMINISTRATOR:	KUHLMANN, MARIA CONNIE		FACILITY TYPE:	740
ADDRESS:	4230 CLAYTON ROAD		TELEPHONE:	(925) 676-3410
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	160	CENSUS: 88	DATE:	04/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Connie Kuhlmann, Executive Director		TIME COMPLETED:	03:00 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 4/21/2023 at 10:00 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Executive Director, Connie Kuhlmann and explained the purpose of the visit. The facility’s fire clearance was approved for 150 Non-Ambulatory and 10 Bedridden. LPA toured the facility with Connie including but not limited to 4 residents’ apartments, bathrooms, activity rooms, kitchen, and common area. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 degrees F. The hot water temperature in a sample of residents’ bathroom were measured at 109 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition. LPA observed sprinkler system. Fire extinguishers were last serviced on 04/21/2022. Emergency disaster drill was last conducted on 04/12/2023. First aid kit was observed to be complete. Report continues to 809 C.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CONCORD ROYALE	FACILITY NUMBER: 075600578
	VISIT DATE: 04/21/2023

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

At 12:50 PM, LPA reviewed 8 of 88 residents records. At 12:00 PM, LPA reviewed 8 staff records and 8 of 8 have current first aid training and associated to the facility. At 12:38 PM, LPA reviewed a sample of 8 of 88 resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/12/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2