075601221-11-29-2023-15-AS-LAWN-CY2SX8-20231129131530

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601221
Report Date: 11/29/2023
Date Signed: 11/29/2023 01:15:39 PM

Document Has Been Signed on 11/29/2023 01:15 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 CARE		FACILITY NUMBER:	075601221
ADMINISTRATOR:	CAMACLANG, ALBERTINA R		FACILITY TYPE:	740
ADDRESS:	2532 LARKEY LANE		TELEPHONE:	(925) 287-8590
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY:	6	CENSUS: 5	DATE:	11/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jennyfe Lagana, Caregiver		TIME COMPLETED:	01:30 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 11/29/2023 at 10:00AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Jennyfe Lagana and explained the purpose of the visit. Jennyfe phoned Administrator, Albertina "Tina" Camaclang and advised. Tina arrived approximately 30 minutes later. The facility’s fire clearance was approved for capacity six (6) clients where all clients may be non-ambulatory and hospice waiver for one (1) client. Administrator Certificate #6010282740 Expires 02/16/2024. LPA toured facility with Jennyfe including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 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 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 116.5 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. LIC 809 Continued...

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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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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: 11/29/2023

NARRATIVE

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LIC 809C Continued

Smoke and carbon monoxide detectors were in operating condition during visit. New fire extinguisher was purchased 09/11/2023. Emergency Disaster Plan was last posted on 07/23/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/12/2023.

At 11:00AM, LPA reviewed 5 residents records. At 12:00PM, LPA reviewed 5 staff records and 4 of 5 have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/06/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Updated Liability Insurance Policy
Updated Facility Sketch

No deficiencies cited during visit. Exit interview conducted 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: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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