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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601014
Report Date: 11/19/2021
Date Signed: 11/19/2021 03:42:43 PM

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:REYES GUEST HOMES-BELFORDFACILITY NUMBER:
075601014
ADMINISTRATOR:RAQUEL Y. COYLEFACILITY TYPE:
740
ADDRESS:2263 BELFORD DR.TELEPHONE:
(925) 280-9975
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Flor ReyesTIME COMPLETED:
04:24 PM
NARRATIVE
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Licensee Flor Reyes. LPA observed all staff wearing face masks during visit. Facility has a completed COVID-19 mitigation plan (LIC 808) in place.

LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. Routine symptom screening (+/-) temperature, symptom check, and Covid-19 vaccination card check is done at entry for all staff, residents, and visitors. LPA observed COVID-19 signs posted in common areas and restrooms to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Regular training has been conducted on infection prevention, symptoms, transmission and proper donning and doffing of PPE. All staff and residents are fully vaccinated.

There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper and PPE supplies are in storage. The facility room temperature was maintained at a comfortable level and the hot water temperature was within the safe 105 to 120 degree range. A certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operation. The Smoke and Carbon monoxide detectors were operational, the fire extinguisher was fully charged and serviced 06/2021.

Facility cited for one Type B violation of Title 22 because of the unsafe use of the HVAC closet for storage. Staff removed the stored items before completion of inspection.

Exit interview was conducted and a copy of this report was provided to the administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REYES GUEST HOMES-BELFORD
FACILITY NUMBER: 075601014
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

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
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Based on observation, the licensee did not comply with the section cited above due to an unsafe use of the HVAC closet for storage, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2021
Plan of Correction
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Violation cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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