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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601290
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:06:47 PM


Document Has Been Signed on 07/21/2022 03:06 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:LA ORINDA CARE HOMEFACILITY NUMBER:
075601290
ADMINISTRATOR:WONG, RONALD G.FACILITY TYPE:
740
ADDRESS:2180 LA ORINDA PLACETELEPHONE:
(925) 798-3570
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 4DATE:
07/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Ronald Wong, AdministratorTIME COMPLETED:
03:20 PM
NARRATIVE
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On 07/21/22, while at the facility for another purpose, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced case management visit, finding that the facility had failed to seek timely medical attention for a resident that was determined to be in an altered state of consciousness, and upon ER presentation was also found to have an unstageable pressure wound; had failed to timely communicate the resident’s change in condition to the PCP and authorized representative & to submit to CCL a written incident report involving the hospitalization; and when Administrator reported to LPA that resident had attending home health nurses during the final 2 weeks at facility could not produce the requested documentation - stating that he allowed the records to be removed by home health without maintaining copies.


Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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


Document Has Been Signed on 07/21/2022 03:06 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: LA ORINDA CARE HOME
FACILITY NUMBER: 075601290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2022
Section Cited

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(1) The licensee shall provide assistance in meeting necessary medical and dental needs.

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This requirement was not met as evidenced by: facility failed to seek timely medical attention for an unstageable pressure wound and altered mental status, which is a threat to health and safety of persons in care.
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Type B
08/15/2022
Section Cited

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(1) A written report shall be submitted to the licensing agency and the person responsible for the resident … (B) Any serious injury … occurring while the resident is under facility supervision.
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This requirement was not met as evidenced by: facility failed to report to responsible party and CCLD of a resident’s hospitalization, which is a potential threat to the health and safety of persons in care.
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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) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/21/2022 03:06 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: LA ORINDA CARE HOME
FACILITY NUMBER: 075601290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2022
Section Cited

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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility … readily available to … to licensing agency staff.
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This requirement was not met as evidenced by: facility failed to maintain home health documentation, which is a potential threat to the health and safety of residents in care
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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) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3