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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075600632
Report Date:
06/23/2023
Date Signed:
06/23/2023 06:34:00 PM
Document Has Been Signed on
06/23/2023 06:34 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:
TENDER TOUCH RESIDENTIAL CARE HOME
FACILITY NUMBER:
075600632
ADMINISTRATOR:
CRUZ, ESTRELLITA S.
FACILITY TYPE:
740
ADDRESS:
58 MIDHILL ROAD
TELEPHONE:
(925) 228-5683
CITY:
MARTINEZ
STATE:
CA
ZIP CODE:
94553
CAPACITY:
6
CENSUS:
6
DATE:
06/23/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:50 PM
MET WITH:
Estrellita Cruz, Licensee/Administrator
TIME COMPLETED:
06:45 PM
NARRATIVE
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On 6/23/2023 at 2:50 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Oscar Santos and explained the purpose of the visit. Licensee/Administrator, Estrellita Cruz arrived shortly after. The facility’s fire clearance was approved for 6 non-ambulatory.
LPA toured facility with Estrellita including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of total 5 bedrooms which 5 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.
Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was purchased 04/19/23. Emergency Disaster Plan was last posted on 01/10/2019. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/01/2023.
LPA reviewed 6 residents records. LPA reviewed 3 staff records and 2 of 3 have current first aid training and associated to the facility.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/23/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
06/23/2023 06:34 PM
- It Cannot Be Edited
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:
TENDER TOUCH RESIDENTIAL CARE HOME
FACILITY NUMBER:
075600632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/23/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in having S2 with health screening and TB test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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Licensee will schedule an appt and send a copy of TB for S2 by POC Due 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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/23/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2023
LIC809
(FAS) - (06/04)
Page:
2
of
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Document Has Been Signed on
06/23/2023 06:34 PM
- It Cannot Be Edited
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:
TENDER TOUCH RESIDENTIAL CARE HOME
FACILITY NUMBER:
075600632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/23/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in by S2 and S3 having expired First Aid/CPR which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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Licensee will send updated First Aid/CPR Certifications to CCL by POC Due Date.
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having R2, R3, R5 did not have Appriasal Needs and Service Plans (ANS) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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Licensee will update ANS and will send updated copies to CCL by POC Due 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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/23/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2023
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
06/23/2023 06:34 PM
- It Cannot Be Edited
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:
TENDER TOUCH RESIDENTIAL CARE HOME
FACILITY NUMBER:
075600632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/23/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in by informing the local fire department of oxygen in use in Bedroom# 4 which posesa poten tial health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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Licensee will notify the local fire department and send a copy of notification to CCL by POC Due Date.
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employess and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in by having oxygen tank, wheelchairs, ladders, ca-modes, suitcase... which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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Licensee will clean the outside yard by removing items and will send a photo to CCL by POC Due 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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/23/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2023
LIC809
(FAS) - (06/04)
Page:
4
of
7
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:
TENDER TOUCH RESIDENTIAL CARE HOME
FACILITY NUMBER:
075600632
VISIT DATE:
06/23/2023
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
At 3:15 PM LPA observed ladder, smoker, pieces of wood outside side yard
At 3:20 PM LPA observed oxygen tank, wheelchair, 3 toilet commodes, suitcase, walkers on opposite outside back yard
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/30/2023:
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
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2023
LIC809
(FAS) - (06/04)
Page:
7
of
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