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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601264
Report Date:
04/27/2023
Date Signed:
04/27/2023 03:09:26 PM
Document Has Been Signed on
04/27/2023 03:09 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
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:
DATE:
04/27/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Licensee Estrellita Cruz
TIME COMPLETED:
03:30 PM
NARRATIVE
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On 04/27/2023 at 9:00 AM Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Required Annual Inspection. Upon entry, LPA disclosed the purpose of the visit with staff. At approximately 10:00 AM, Licensee Estrellita Cruz arrived.
During inspection, LPA inspected the physical plant inside and outside, including the kitchen, bedrooms, bathrooms, garage, and all other rooms within the facility. LPA also reviewed resident, staff, facility files, and interviewed both residents and staff.
4 Type A and 2 Type B citations were issued (refer to LIC809-D for details).
Additional visit will be required to complete annual inspection.
Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
04/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/27/2023
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
5
Document Has Been Signed on
04/27/2023 03:09 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
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:
04/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(7)(B)
87208 PLAN OF OPERATION (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility ... shall contain the following: (7) Sketches ... (B) The grounds showing buildings, driveways, fences, storage areas, pools, gardens, recreation area and other space used by the residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 facility sketches, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/04/2023
Plan of Correction
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4
Licensee shall create and post the floor plan and yard sketches accurately depicting the facility and inform the LPA on or before the due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
04/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/27/2023
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
04/27/2023 03:09 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
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:
04/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, the licensee did not comply with the section cited above in the bathroom cabinet where cleaning supplies stored, which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/28/2023
Plan of Correction
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2
3
4
Cleared during visit when staff locked cabinet door.
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 refrigerated medication storage locations that must be locked, which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/28/2023
Plan of Correction
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2
3
4
Cleared during visit when staff locked and removed key from refrigerator.
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:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
04/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/27/2023
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
04/27/2023 03:09 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
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:
04/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the garage where laundry soap was stored next to food (Ensure], which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/28/2023
Plan of Correction
1
2
3
4
Cleared during visit when staff moved laundry detergent to locked cabinet.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the kitchen where staff stored scissors in an unlocked drawer, which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/28/2023
Plan of Correction
1
2
3
4
Cleared during visit when staff removed scissors and placed them in a locking drawer.
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:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
04/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/27/2023
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
04/27/2023 03:09 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
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:
04/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the exterior of the facility, where a section of gutter was broken and left hanging above the threshold of the front porch and the front door leading into the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/15/2023
Plan of Correction
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3
4
During the visit, staff blocked access there and directed visitors to alternative entrances for a temporary solution. Licensee shall have gutter professionally repaired on or before due date. Licensee shall send proof of repair to LPA on or before due date.
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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
04/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/27/2023
LIC809
(FAS) - (06/04)
Page:
5
of
5