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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601221
Report Date: 12/28/2022
Date Signed: 12/29/2022 04:17:15 PM


Document Has Been Signed on 12/29/2022 04:17 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:LARKEY PARK HOME CAREFACILITY NUMBER:
075601221
ADMINISTRATOR:CAMACLANG, ALBERTINA RFACILITY TYPE:
740
ADDRESS:2532 LARKEY LANETELEPHONE:
(925) 287-8590
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:6CENSUS: 5DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Maryann Sison, CaregiverTIME COMPLETED:
06:15 PM
NARRATIVE
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On 12/28/22 at 2:46 PM, Licensing Program Analyst (LPA) L. Alexander and Licensing Program Manager (LPM) J. Fong arrived unannounced to conduct 1-Year Annual Required inspection. LPA and LPM met with Caregivers, Maryann Sison and Mariana Radut and explained the purpose of the visit. The Administrator, Albertina Camaclang arrived approx. 3:34pm.

LPA toured facility with Maryann Sison and Mariana Radut including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 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 72 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 111 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. Fire extinguisher was last serviced on 9/21/2022.

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

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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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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: LARKEY PARK HOME CARE
FACILITY NUMBER: 075601221
VISIT DATE: 12/28/2022
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At 3:10pm LPA/LPM observed trashbins without lids and step
At 3:15pm the front and two side doors had inoperable alarms
At 3:17pm no oxygen signage for Resident


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/04/2023:

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

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

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/29/2022 04:17 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: LARKEY PARK HOME CARE
FACILITY NUMBER: 075601221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87611(b)(3)(B)
In addition to Section 87611(b), the licensee shall be responsible for the following:
(B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.


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 assuring appropriate oxygen signs which poses an potential health and safety risk to persons in care.
POC Due Date: 01/04/2023
Plan of Correction
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By POC date, facility will submit to CCLD photographs of "Oxygen in Use" signage at the outside front entry, and at the subject resident's outside bedroom door.
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 ensuring alert monitoring which poses potential health and safety risk to persons in care.
POC Due Date: 01/04/2023
Plan of Correction
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By POC date, Administartor will replace the batteries to the alarms on the two side doors and the front entry door. Administrator replaced the batteries in the presence of the LPA and LPM during the visit. POC cleared.
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: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4