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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600883
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:01:07 PM


Document Has Been Signed on 02/21/2024 02:01 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 HOMEFACILITY NUMBER:
075600883
ADMINISTRATOR:PILARKSI, ADELINAFACILITY TYPE:
740
ADDRESS:67 COLLEGE WAYTELEPHONE:
(925) 323-6428
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 5DATE:
02/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Keith Mauer, AdministratorTIME COMPLETED:
02:20 PM
NARRATIVE
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On 02/21/2024 at 11:55 am, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct Case Management visit. LPA met with Administrators, Keith & Stephanie Mauer and explained the purpose of the visit. LPA conducted an Annual Inspection on 12/14/2023 and cited facility. The original Plan of Correction (POC) was scheduled for 01/11/2024. The administrator requested an additional 30 Day extension on 01/08/2024 in which LPA L. Alexander granted the request and confirmed that the new due date is 02/09/2024. Due to LPA L. Alexander was not able to return to the facility for a POC visit, LPA returned to recite and cite for new deficiencies.

LPA L. Alexander conducted an Annual Inspection on 12/14/2023 and cited facility for the following:

  • CCR 87411(f) Personnel Requirements – General – Health Screening and TB - deficiencies not cleared
  • HSC 1569.695(c) - Fire Drill - deficiency cleared
  • CCR 87412(b)(3)(B) Personnel Records - deficiencies cleared
  • CCR 87705(c)(6) Care of Persons with Dementia – Appraisals -deficiency cleared
  • CCR 87705(f)(1) Care of Persons with Dementia – Toxic Chemicals –cleared during visit on 12/14/2023
  • HSC 1569.618(c)(3) First Aid and CPR – deficiency cleared


LIC 809 Continued...

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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 4


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: 02/21/2024
NARRATIVE
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LIC809-C Continued...

LPA L. Alexander conducted an Annual Inspection on 12/14/2023 and will recite and cite facility for the following today:

  • CCR 87411(f) Personnel Requirements – Health Screening and TB Results for S1, S2, S5
  • CCR 87705 (5) Care of Persons with Dementia - Medical Assessment for R1
  • CCR 87458 (a) Medical Assessment - Medical Assessment for R5
  • HSC 1569.605 Liability insurance; coverage requirements $1,000,000.00 each injury occurrence to $3,000,000.00 total aggregate occurrence

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.



Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 02/21/2024 02:01 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: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2024
Section Cited
CCR
87411(f)

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(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of...

This requirement is not met as evidenced by:
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Administrator agreed to obtain health screening for S1, S2, S5 and TB test results for S2. Administrator will submit a copy of health screening with TB test result to CCLD by POC date.
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Based on interview and record review, the licensee did not comply with the section cited above in by not having health screening for S1, S2, S5 and TB tests for S2 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
03/18/2024
Section Cited
CCR87705(5)

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87705 Care of Persons with Dementia
(5) Each resident with dementia shall have an annual medical assessment ...

This requirement is not met as evidenced by:
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Administrator agreed to obtain updated Physician's Report for R1 and submit a copy to CCLD by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above in by not having an updated annual medical assessment for R1 which poses a potential health, safety or personal rights risk to persons in 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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 02/21/2024 02:01 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: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2024
Section Cited
CCR
87458(a)

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87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file...
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Administrator agreed to obtain an updated Physician's Report and submit to CCLD by POC due date.
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Based on record review, the licensee did not comply with the section cited above in by not having an updated annual medical aseessment for R5 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
02/26/2024
Section Cited
HSC1569.605

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Liability insurance; coverage requirements...all residential care facilities for the elderly,...shall maintain liability insurance
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Administrator agreed to get the Evidence of Coverage for Liability Insurance and send a copy to CCLD by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above in by not having adequate liability insurance which poses a potential health, safety or personal rights risk to persons in 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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4