075601014-11-8-2024-15-AS-JSAR-DATUXF-20241108145816

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601014
Report Date: 11/08/2024
Date Signed: 11/08/2024 02:58:36 PM

Document Has Been Signed on 11/08/2024 02:58 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-BELFORD		FACILITY NUMBER:	075601014
ADMINISTRATOR/ DIRECTOR:	RAQUEL Y. COYLE		FACILITY TYPE:	740
ADDRESS:	2263 BELFORD DR.		TELEPHONE:	(925) 280-9975
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Administrator Alberto Bernardino		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 11/08/2024 at 8:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPA stated the purpose of the visit to Staff Members CONNIE VILLARETE and BONAFE QUIBLAT. Administrator Alberto Bernardino arrived at approximately 9:55 AM. The LPA inspected the interior and exterior of the facility. The inspection of the physical plant included the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, garage, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. At approximately 10:55 AM, the kitchen hot water temperature was 124.3 degrees and the living room temperature was 71.1 degrees Fahrenheit. The fire extinguisher was last serviced on 9/16/2024. The carbon monoxide and smoke detectors were fully operational. The LPA observed required postings in the facility, including the Residential Care Facility for the Elderly Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPA reviewed the facility records, records of 5 residents, and records of 5 staff members. 3 Type-A and 3 Type-B citations were issued during the inspection. Exit interview conducted and a copy of this report provided.

Harpreet Humpal	TELEPHONE: (510) 529-9416
James Sampair	TELEPHONE: (510) 286-4201
	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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 11/08/2024 02:58 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: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... 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 1 of 2 gates that was locked, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/09/2024
	Plan of Correction
1 2 3 4	Staff unlocked and removed the lock from the gate.

Section Cited

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the kitchen by storing knives and scissors in an unlocked drawer, which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/09/2024
	Plan of Correction
1 2 3 4	Staff removed knives and scissors from unlocked drawer.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Harpreet Humpal	TELEPHONE: (510) 529-9416
James Sampair	TELEPHONE: (510) 286-4201
	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/08/2024 02:58 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: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following: (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden 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 1 out of 6 non-ambulatory rooms, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Licensee shall submit an LIC 200 with an updated facility sketch (LIC 999) to the Oakland Regional Office.

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.

Harpreet Humpal	TELEPHONE: (510) 529-9416
James Sampair	TELEPHONE: (510) 286-4201
	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/08/2024 02:58 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: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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. The hot water temperature was 123.1 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/09/2024
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall send proof to LPA Sampair that the hot water temperature has been reduced to the safe range of 105 to 120 degrees Fahrenheit.

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.

Harpreet Humpal	TELEPHONE: (510) 529-9416
James Sampair	TELEPHONE: (510) 286-4201
	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/08/2024 02:58 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: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. 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 out of 3 showers that had no non-skid mats or strips, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Staff cleared citation during inspection by obtaining non-skid mats for the showers and adding them to the showers.

Section Cited

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 1 out of 6 non-ambulatory rooms by providing no proof of a building permit for construction that added an exterior door and a ramp to a non-ambulatory room, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall send a copy of the building permit for the construction to LPA Sampair.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Harpreet Humpal	TELEPHONE: (510) 529-9416
James Sampair	TELEPHONE: (510) 286-4201
	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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