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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075600975
Report Date:
06/23/2023
Date Signed:
06/23/2023 05:55:07 PM
Document Has Been Signed on
06/23/2023 05:55 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
TENDER TOUCH RESIDENTIAL CARE HOME II
FACILITY NUMBER:
075600975
ADMINISTRATOR:
FE G DIMAANO
FACILITY TYPE:
740
ADDRESS:
2053 DORSCH ROAD
TELEPHONE:
(925) 947-1421
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94598
CAPACITY:
6
CENSUS:
5
DATE:
06/23/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:35 AM
MET WITH:
Fe Dimaano
TIME COMPLETED:
06:15 PM
NARRATIVE
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On 06/23/2023 at 08:35 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct an Annual Inspection. Upon entry, LPA stated the purpose of the visit to Staff Members Purificacion Mapa and Manuel Baldeo. Administrator (ADM) Fe Dimaano arrived at approximately 9:00 AM.
LPA and ADM toured the facility inside and outside. The LPA conducted interviews of 2 residents and 2 staff members. LPA reviewed files of 5 staff and 5 residents.
During this inspection, 2 Type-A and 5 Type-B citations issued (refer to LIC809-D for details).
Exit interview conducted with ADM. A copy of this report provided by LPA via email.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
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:
1
of
5
Document Has Been Signed on
06/23/2023 05:55 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
TENDER TOUCH RESIDENTIAL CARE HOME II
FACILITY NUMBER:
075600975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/23/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above with 1 of the 2 backyard gates being locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2023
Plan of Correction
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2
3
4
Gate repaired during inspection.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the kitchen where scissors left in unlocked drawer, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2023
Plan of Correction
1
2
3
4
scissors removed from unlocked drawer during inspection
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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
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
5
Document Has Been Signed on
06/23/2023 05:55 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
TENDER TOUCH RESIDENTIAL CARE HOME II
FACILITY NUMBER:
075600975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/23/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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 in the backyard, where the decking has 3 holes and rotting wood and the fence is leaning in, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/09/2023
Plan of Correction
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2
3
4
Licensee shall: (1) repair backyard deck: replace rotting wood and cover the 3 holes and (2) stabilize backyard fence that's leaning in. Inform LPA when complete.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
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 with screens with holes and a missing screen door on the exit from the living room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/09/2023
Plan of Correction
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2
3
4
Licensee shall replace screens in those with holes and install new screen door on the exit from the living room and inform LPA when complete.
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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
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
5
Document Has Been Signed on
06/23/2023 05:55 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
TENDER TOUCH RESIDENTIAL CARE HOME II
FACILITY NUMBER:
075600975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/23/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.
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 in the garage where, with no building permit, alterations were made to the garage, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/09/2023
Plan of Correction
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2
3
4
By the due date, the Licensee shall get written confirmation from the City of Walnut Creek that changes made are acceptable as is. If no written confirmation may be obtained by the due date, then picture proof that they have been removed shall be sent to the LPA.
required no permit and with no building permit, alterations were made to the garage
Type B
Section Cited
HSC
1569.695(a)(1)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above and has inaccuracies in sketches and there is no assembly point in the yard sketch, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/30/2023
Plan of Correction
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4
Licensee shall send and post in facility a corrected yard sketch with the assembly point and an accurate floor plan sketch, sending both to LPA.
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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
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
5
Document Has Been Signed on
06/23/2023 05:55 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
TENDER TOUCH RESIDENTIAL CARE HOME II
FACILITY NUMBER:
075600975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/23/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.
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 in 2 of 2 backyard gates were not self-closing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/30/2023
Plan of Correction
1
2
3
4
Repairs were made to the gates during the insection.
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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
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:
5
of
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