075600883-1-6-2023-15-AS-LAWN-CMTVDC-20230106152031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600883
Report Date: 01/06/2023
Date Signed: 01/06/2023 03:20:48 PM

Document Has Been Signed on 01/06/2023 03:20 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:	SUNVALLEY RESIDENTIAL CARE HOME		FACILITY NUMBER:	075600883
ADMINISTRATOR:	PILARKSI, ADELINA		FACILITY TYPE:	740
ADDRESS:	67 COLLEGE WAY		TELEPHONE:	(925) 323-6428
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 4	DATE:	01/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Keith Mauer and Stephanie Salas Mauer		TIME COMPLETED:	03:40 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 01/06/23 at 10:17AM, Licensing Program Analyst (LPA) L. Alexander and Licensing Program Manager (LPM) J. Fong arrived unannounced to conduct 1-Year Annual Required inspection. LPA and LPM met with Administrators, Keith Mauer and Stephanie Salas Mauer and explained the purpose of the visit. LPA toured facility with Keith and Stephanie including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of total 6 bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA and LPM 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 125.2 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. Fire extinguisher was last serviced on 09/15/2020. First aid kit was observed to be complete.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: SUNVALLEY RESIDENTIAL CARE HOME	FACILITY NUMBER: 075600883
	VISIT DATE: 01/06/2023

NARRATIVE

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The following deficiencies were observed:

- Paint was accessible in the backyard
- Vitamins for a former resident were observed by LPA and LPM accessible in the kitchen.
- Fire extinguisher was last checked over 12 months ago.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/13/2023:

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

The 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.

Exit Interview conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5

Document Has Been Signed on 01/06/2023 03:20 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: SUNVALLEY RESIDENTIAL CARE HOME	FACILITY NUMBER: 075600883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Paint was accessible in the back yard and vitamins in the kitchen were unlocked which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/07/2023
	Plan of Correction
1 2 3 4	Administrator secured the paint in the presence of the LPA and LPM; Administrator will submit a copy of the medication destruction record for the vitamins by the 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 01/06/2023 03:20 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: SUNVALLEY RESIDENTIAL CARE HOME	FACILITY NUMBER: 075600883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87293

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	Administrators purchased and obtained a new fire extinguisher while LPA and LPM were at facility. Deficiency cleared.

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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

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