<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601202
Report Date: 09/05/2024
Date Signed: 09/05/2024 03:46:18 PM


Document Has Been Signed on 09/05/2024 03:46 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 LIVINGFACILITY NUMBER:
075601202
ADMINISTRATOR:MARSALA, TERRI L.FACILITY TYPE:
740
ADDRESS:2491 MALLARD DRIVETELEPHONE:
(925) 933-4144
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:9CENSUS: 7DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Laly Bascao, AdministratorTIME 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 09/05/2024 at 11:10 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Laly Bascao and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of nine (9) residents in which two (2) may be Bedridden. Hospice waiver for six (6) residents. Administrator certificate #6058791740 expires 02/15/2025.

LPA toured facility with Laly including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 7 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA 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 105 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 01/02/2024. Emergency Disaster Plan was last posted on 02/01/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/15/2024.

LPA reviewed seven (7) residents records. LPA reviewed four (4) staff records and 3 of 4 have current first aid training and associated to the facility.


LIC809- C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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 4


Document Has Been Signed on 09/05/2024 03:46 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: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 in by not having S2 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
1
2
3
4
Administrator associated S2 to facility by submitting LIC9182 with US Issued Picture ID during visit. Deficiency cleared. Immediate Civil Penalty Assessed for $500.00 today.
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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 09/05/2024 03:46 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: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87623(b)(2)(B)
87623 Indwelling Urinary Catheter
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(2) Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance.
(B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed.


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 in by not having written documentation by an appropriately skilled professional outling the care of R1's foley catheter which poses a potential health and safety risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
1
2
3
4
Administrator will submit documentation outlining bag and tubing are changed by an appropriately skilled professional and instructions of the procedures delegated and the names of the facility staff who have been instructed to empty the catheter bag to CCLD by POC date.
Type B
Section Cited
CCR
87463
87463 Reappraisals

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 in by not having an Appraisal Needs and Services (ANS) for R1's foley catheter that documents that the bag and tubing are changed by an appropriately skilled professional and appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed to empty the cathter bag which poses a potential health and safety risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
1
2
3
4
Administrator will submit an ANS for R1 and submit to CCLD by POC 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: 09/05/2024
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
26
27
28
29
30
31
32
LIC809-C Continued...

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 CCL by 09/12/2024:

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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4