075601264-6-23-2021-15-AS-LIBO-C49RD6-20210623125525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601264
Report Date: 06/23/2021
Date Signed: 06/23/2021 12:57:30 PM

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:	TENDER TOUCH RESIDENTIAL CARE HOME III		FACILITY NUMBER:	075601264
ADMINISTRATOR:	CRUZ, ESTRELLITA S.		FACILITY TYPE:	740
ADDRESS:	2130 DORSCH ROAD		TELEPHONE:	(925) 256-6879
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 6	DATE:	06/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	CRUZ, ESTRELLITA S.		TIME COMPLETED:	01:20 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 6/23/2021, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with staff Florante Dizon and informed the purpose of visit, while conducting facility tour, Administrator Estrelita Cruz joined LPA on facility tour. Facility has census of 6.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. Facility has enough supplies of paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.
Facility has enough 2-day perishable food and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan.

LPA observed the following:
Licensee/Administrator has NOT provided all staff fit testing for N95 respirators- Facility Administrator will schedule FIT testing for all staff, report needed to be LPA, on or before 7/16/2021.

Facility DO NOT HAVE an adequate 30-day supply of PPE (e.g., respirators, gowns, eye protection such as face shield or goggles)

PPE supplies is NOT stored in a location that is readily accessible to staff.

Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control.

.....Continued to LIC809C....

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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 3

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: TENDER TOUCH RESIDENTIAL CARE HOME III	FACILITY NUMBER: 075601264
	VISIT DATE: 06/23/2021

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

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Administrator Estrelita Cruz

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: TENDER TOUCH RESIDENTIAL CARE HOME III	FACILITY NUMBER: 075601264
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in all Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & interview the licensee did not comply with the section cited above facility DO NOT HAVE an adequate 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles) , PPE supplies is NOT stored in a location that is readily accessible to staff, which poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 07/09/2021
	Plan of Correction
1 2 3 4	Facility Administrator will order PPE supplies for the facility and store it one location that is easily accessible for all staffs, a photo will need to be sent to LPA as evidence on or before 7/9/2021.

Type B

Section Cited

CCR

87411(d)(5)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & interview , the licensee did not comply with the section cited above facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control which poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 07/02/2021
	Plan of Correction
1 2 3 4	Facility Administrator will need to train all staff regarding infection prevention, transmission and PPE , proof of training document need to be submitted to LPA on or before 7/2/2021.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3