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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600632
Report Date: 07/18/2023
Date Signed: 07/18/2023 05:35:22 PM


Document Has Been Signed on 07/18/2023 05:35 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 HOMEFACILITY NUMBER:
075600632
ADMINISTRATOR:CRUZ, ESTRELLITA S.FACILITY TYPE:
740
ADDRESS:58 MIDHILL ROADTELEPHONE:
(925) 228-5683
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 6DATE:
07/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Artemia Kaipat, CaregiverTIME COMPLETED:
06:00 PM
NARRATIVE
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On 07/18/2023 at 3:25 PM, Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla arrived unannounced to conduct a POC Visit. LPAs met with Caregiver, Artemia Kaipat and explained the purpose of the visit. Administrator/Licensee, Estrellita Cruz was not available. However, LPAs spoke with Estrellita on the phone to discuss the purpose of visit and the assessed civil penalties. Estrellita authorized Artemia Kaipat to sign the report.

Facility was assessed civil penalty for failure to correct the following deficiencies:
Sec 87411(f) - $100x11 days = $1,100
Sec H&S 1569.618(c)(3) - $100x11 days = $1,100
Sec 1569.695(e)(2) - $100x11 days = $1,100
Sec 87618(b)(3)(A) - $100x11 days =$1,100
Sec 80087(a) - $100x11 days = $1,100


While at the facility, LPAs were advised that the facility has 3 residents who are on hospice care. Facility has only a waiver approved for 2 hospice residents.

Deficiency is cited per Title 22 California Code of Regulations (Refer to Lic 809D).

Exit interview was conducted with Kaipat. A copy of this report and Appeal Rights were provided.






SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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 07/18/2023 05:35 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: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
Section Cited
CCR
87632(a)

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87632 Hospice Care Waiver
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have ....
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By POC date, Administrator will submit to CCL request for additional hospice waiver.
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This requirement is not met as evidenced by: Facility retained 3 hospice residents but has an approved waiver for 2 which poses a potential risk to health and safety of clients under 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
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