075601202-8-22-2023-15-AS-LAWN-CUY466-20230822184900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601202
Report Date: 08/22/2023
Date Signed: 08/22/2023 06:49:12 PM

Document Has Been Signed on 08/22/2023 06:49 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	AMARYLLIS ASSISTED LIVING		FACILITY NUMBER:	075601202
ADMINISTRATOR:	MARSALA, TERRI L.		FACILITY TYPE:	740
ADDRESS:	2491 MALLARD DRIVE		TELEPHONE:	(925) 933-4144
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY:	9	CENSUS: 6	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Laly Barcao, Co-Administrator		TIME COMPLETED:	07:15 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 08/22/2023 at 2:50 PM, Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Caregiver, Evaruth Olkerill and explained the purpose of the visit. The Co-Administrator, Laly Bascao arrived approx. 3:15 PM. The Licensee/Administrator, Terri Marsala, was not available. The facility’s fire clearance was approved for 9 non-ambulatory and a hospice waiver for two (2) residents. LPAs toured facility with Eva including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 9 total bedrooms which 8 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.4 degrees Fahrenheit. 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. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/12/2023. Emergency Disaster Plan was last posted in 2019. First aid kit was observed to be complete. LIC 809C....Continued

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 08/22/2023 06:49 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMARYLLIS ASSISTED LIVING	FACILITY NUMBER: 075601202
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in having a bedridden resident without an approved bedriddenfire clearance for R4 (resident #4) which poses an immediate health and safety to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will submit a formal letter requesting bedridden, submit an updated facility sketch to CCLD by POC Due Date.

Type A

Section Cited

CCR

87608(a)(5)(b)

(a) Based on the individual's preadmission appraisal...Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving.... (B) Bed rails that extend...currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in not having R4 without an approved exception and R4 is not on hospice care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will submit a request for exception to use full bed rail for R4. Request shall be submitted to CCLD by POC Due Date.

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 Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMARYLLIS ASSISTED LIVING	FACILITY NUMBER: 075601202
	VISIT DATE: 08/22/2023

NARRATIVE

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LIC 809 Continued....

LPAs reviewed 5 residents records. LPAs reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 3:20 PM LPAs observed during tour and record review that R4 was bedridden without proper bedridden fire clearance

At 4:00 PM LPAs observed during tour and record review that R4 does not have doctor's order and approved exception on file for full rail hospital bed.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by : 08/29/2023

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Facility Sketch
Current Administrator’s Certificate

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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