075600578-5-21-2025-15-AS-PMAO-DGVUEN-20250521153124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600578
Report Date: 05/21/2025
Date Signed: 05/21/2025 03:31:39 PM

Document Has Been Signed on 05/21/2025 03:31 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	CONCORD ROYALE		FACILITY NUMBER:	075600578
ADMINISTRATOR/ DIRECTOR:	KUHLMANN, MARIA CONNIE		FACILITY TYPE:	740
ADDRESS:	4230 CLAYTON ROAD		TELEPHONE:	(925) 676-3410
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY: 160	TOTAL ENROLLED CHILDREN: 0	CENSUS: 85	DATE:	05/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Connie Kuhlmann, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	03:45 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 05/21/2025 at 9:45 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, Connie Kuhlmann and explained the purpose of the visit. The facility’s fire clearance was approved for 160 residents all may be non-ambulatory and 15 hospice and total care waivers. LPAs toured the facility inside and out including but not limited to 7 residents' apartments, bathrooms, multiple activity rooms, kitchen, and dining hall. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained between 72 to 74 degrees F all around the facility. The hot water temperature in sample of residents’ shared bathroom were measured at 116.9, 114, 112.7, 109, 108.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pan. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 05/15/2025. Emergency Disaster Plan was last posted on 03/05/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 04/25/2025. At 11:52 AM, LPAs reviewed 7 residents records. At 12:20 PM, LPAs reviewed 6 staff records and 5 of 6 have current first aid training and 6 of 6 associated to the facility. At 2:30 PM, LPAs reviewed two sample of resident’s medications. Continue LIC809-C...

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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 5

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 5

Document Has Been Signed on 05/21/2025 03:31 PM - It Cannot Be Edited

Created By: Patricia Manalo On 05/21/2025 at 02:32 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: CONCORD ROYALE	FACILITY NUMBER: 075600578
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(29)

(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by having the freezer door not capable of closing all the way and food was observed to have freezer burn which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/11/2025
	Plan of Correction
1 2 3 4	The Executive Director agrees to fix the freezer door, get rid of the food items with freezer burn, and send proof 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.

	Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (510) 286-4201

	Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 432-7785

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CONCORD ROYALE	FACILITY NUMBER: 075600578
	VISIT DATE: 05/21/2025

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

Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 05/29/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT:

At 11:15 AM, LPAs observed freezer burn in the freezer. Interview with kitchen staff stated that the freezer door was not capable of closing all the way.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Executive Director. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia Manalo	TELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5