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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601014
Report Date: 11/15/2023
Date Signed: 11/15/2023 05:30:40 PM


Document Has Been Signed on 11/15/2023 05:30 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
OAKLAND ASC, 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: 4DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Caregiver Edelita PineTIME COMPLETED:
05:45 PM
NARRATIVE
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On 11/15/2023 at 3:45 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct an annual inspection. Upon arrival, LPA explained the purpose of the visit to Caregiver Edelita Pine. Administrator (ADM) Raquel Coyle arrived at approximately 4:30 PM.

During the Inspection, the LPA inspected the facility inside and outside. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 68 degrees Fahrenheit. The LPA observed that the lighting in all rooms is adequate for the comfort and safety of the residents. 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. Sharps were locked and inaccessible to residents. Fire extinguishers observed to be fully charged.

Annual inspection is incomplete. The LPA will return unannounced at a later date to complete the inspection.

1 Type-A citation was issued during the visit.

Exit interview conducted with ADM. A copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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Document Has Been Signed on 11/15/2023 05:30 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: REYES GUEST HOMES-BELFORD
FACILITY NUMBER: 075601014

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(3)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements:

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 for 1 of 1 residents using oxygen because (1) no report to fire dept in writing, (2) insecure non-portable oxygen tank, and (3) no "No Smoking Oxygen in Use" sign posted on the front door which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Licensee must: (1) report to fire dept in writing, (2) must secure non-portable oxygen tank to the wall, and (3) must post "No Smoking Oxygen in Use" sign on the front door.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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