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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601264
Report Date: 07/17/2023
Date Signed: 07/17/2023 05:56:49 PM


Document Has Been Signed on 07/17/2023 05:56 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:TENDER TOUCH RESIDENTIAL CARE HOME IIIFACILITY NUMBER:
075601264
ADMINISTRATOR:CRUZ, ESTRELLITA S.FACILITY TYPE:
740
ADDRESS:2130 DORSCH ROADTELEPHONE:
(925) 256-6879
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
07/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Fe DimaanoTIME COMPLETED:
06:30 PM
NARRATIVE
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On 07/17/2023 at 3:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for a pre-licensing inspection. LPA explained purpose of the visit to Administrator (ADM) Fe Dimaano.

LPA and ADM toured facility and reviewed facility files.

Pre-Licensing is incomplete with deficiencies to be resolved by 7/31/2023. A follow up Pre-licensure visit will be made upon resolution of deficiencies.

Exit interview conducted with ADM. A copy of this report provided for ADM by LPA via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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 2


Document Has Been Signed on 07/17/2023 05:56 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
OAKLAND ASC, 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: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2023
Section Cited
CCR
87204(b)

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LIMITATIONS -- CAPACITY AND AMBULATORY STATUS: (b) Resident rooms approved for ... ambulatory residents only ... shall not accommodate nonambulatory residents.

This requirement is not met as evidenced by:
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Licensee shall move the nonambulatory residents in rooms 1 and 2 into other rooms that are approved for nonambulatory residents. Licensee shall inform LPA that the residents have been moved on or before the due date.
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Based on observation, the licensee did not comply with the section cited above in 2 out of 6 rooms in the facility, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/31/2023
Section Cited
CCR87208(a)(7)(A)

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PLAN OF OPERATION (a) Each facility shall have and maintain a current ... (7) Sketches ... (A) ... including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents
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Licensee shall create new facility sketches for yard and floor plan that have: (1) name of new facility and (2) correct room numbering that corresponds with license and includes which rooms are for nonambulatory or ambulatory resident written clearly on the floor plan sketch and
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Requirement not met as evidenced by:

Based on observation, the licensee did not comply with the section cited above with an inaccurate floor sketch, which poses a potential health, safety or personal rights risk to persons in care.
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 (3) ensure that the size of the sketches are of appropriate size to be posted on the wall of the facility.
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) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2