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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601180
Report Date: 11/28/2022
Date Signed: 11/28/2022 01:40:39 PM


Document Has Been Signed on 11/28/2022 01:40 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:WELCOME HOME SENIOR RESIDENCE (WALNUT CREEK)FACILITY NUMBER:
075601180
ADMINISTRATOR:CHOU, STEVEFACILITY TYPE:
740
ADDRESS:2421 WASDEN COURTTELEPHONE:
(925) 944-0204
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 4DATE:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Jellyn BuenvenidaTIME COMPLETED:
02:20 PM
NARRATIVE
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On 11/28/2022 Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. LPA was greeted by staff member Jellyn Buenvenida and explained the purpose of the visit.

LPA inspected the inside and outside of the facility, observing that all of the staff wore a face mask at all times. LPA observed a screening station located near the front entrance with hand sanitizer, a no-touch thermometer, visitor's log, face masks, question concerning and recording of visitor vaccination status for staff, residents, and visitors.

LPA observed COVID-19 signs posted in common areas to promote hand washing and physical distancing. Staff documents temperature and health status for staff and residents on a daily basis.


Facility room temperature was maintained at a comfortable temperature and the hot water was within the safe temperature of 105 to 120 degrees Fahrenheit. There were sufficient food and water supplies in the kitchen refrigerators/freezers.

Fire extinguishers were observed fully charged and the Smoke and Carbon monoxide detectors were fully operational.

Facility cited for malfunctioning auditory device on exterior door.

Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
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 2


Document Has Been Signed on 11/28/2022 01:40 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: WELCOME HOME SENIOR RESIDENCE (WALNUT CREEK)
FACILITY NUMBER: 075601180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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 in 1 instance, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2022
Plan of Correction
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Licensee shall replace malfunctioning auditory device with fully functioning device.
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: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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