075601014-9-21-2022-15-AS-JSAR-CJGQ5S-20220921115226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601014
Report Date: 09/21/2022
Date Signed: 09/21/2022 11:53:51 AM

Document Has Been Signed on 09/21/2022 11:53 AM - 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:	REYES GUEST HOMES-BELFORD		FACILITY NUMBER:	075601014
ADMINISTRATOR:	RAQUEL Y. COYLE		FACILITY TYPE:	740
ADDRESS:	2263 BELFORD DR.		TELEPHONE:	(925) 280-9975
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 6	DATE:	09/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Raquel Coyle and Flor Reyes		TIME COMPLETED:	12:00 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 9/21/22 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit to staff and conducted the initial inspection inside and outside of the facility. Administrators Raquel Coyle and Flor Reyes arrived later and together they discussed the LPA's findings and any deficiencies identified during the inspection. Facility has an infection control plan in place that they are following. The administrators are the designated infection control leaders. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. Facility had signs posted to promote hand washing and mask wearing. The fire extinguisher has been serviced within the past 12 months, The carbon monoxide and smoke detectors were fully functional. The temperature inside of the facility was 69.8 and the hot water was 112 degrees, both in the safe temperature range. An administrator is on site at least the required 20 hour minimum each week to oversee business operations. Facility cited for 3 Type B deficiencies due to non-regulation medicine dispensing practices, not conducting quarterly emergency drills, and converting a shed into a bedroom that was being used by a staff member (refer to LIC 809-D). Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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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Document Has Been Signed on 09/21/2022 11:53 AM - 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: REYES GUEST HOMES-BELFORD	FACILITY NUMBER: 075601014
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2022

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 because they have allowed a shed to be converted into a bedroom where a staff member has been living part-time, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2022
	Plan of Correction
1 2 3 4	Licensee must convert shed back to being a shed and not a bedroom for use by anyone.

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 6 of the 6 resident's medications with the use of transfer containers to dispense them to the residents on a daily basis, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2022
	Plan of Correction
1 2 3 4	Licensee must remove the transfer containers, update the plan of operation, and retrain staff to dispense the medications to residents directly from the originally received containers at time of dispensing.

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: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2022 11:53 AM - 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: REYES GUEST HOMES-BELFORD	FACILITY NUMBER: 075601014
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 since the last emergency drill that was conducted in September of 2021, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2022
	Plan of Correction
1 2 3 4	Licensee shall conduct an emergency drill on or before the due date and attest to LPA that the drill has been conducted via email or text.

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: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC809 (FAS) - (06/04)

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