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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601290
Report Date: 08/28/2024
Date Signed: 08/28/2024 01:57:28 PM


Document Has Been Signed on 08/28/2024 01:57 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:
08/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:ASHA JAIN, ADMINISTRATORTIME COMPLETED:
02:20 PM
NARRATIVE
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LPA Carol Fowler arrived at facility unannounced to conduct a Pre-Licensing visit.

On 08/28/2024, while conducting a Pre-Licensing visit LPA observed the following deficiencies
  • LPA observed bathtub needs to be cleaned.
  • LPA observed the toilet tank is not fitting the back of the toilet.
  • LPA observed the water temperature in residents shared bathroom is 124.9.
  • LPA observed a storage unit located in the back yard unlocked.
  • LPA observed a cabinet located in the garage has an open area.
  • LPA observed mattresses, bed rails, tools, shovel, walker, boxes and other items in the garage.
  • LPA observed the kitchen hood needs to be cleaned.
  • LPA observed unlocked medication in the kitchen drawer.



Type A&B Deficiencies are cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Corrections (POC's) by Plan of Correction date may result in civil penalties.

Exit interview conducted a copy of this report and Appeal Rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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Document Has Been Signed on 08/28/2024 01:57 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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
HSC
87465(h)(2)

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Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication.
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Caregiver locked medication during visit. DEFICIENCY CLEARED DURING VISIT.
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Based on observation, facility did not comply with section cited above by having unlocked medication in a kitchen drawer which poses an immediate health and safety risk to the residents in care.
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Type A
08/29/2024
Section Cited
CCR87303(e)(2)

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(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and g... shall deliver hot water. Hot water temperature controls shall be maintained to ...regulate the...
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Administrator agreed to adjust water temperature and submit a video to the Department by the POC date.
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temperature of hot water used by residents to at... temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Based on observation, facility did not comply with section cited above by having water temperature 124.9 which poses an immediate health and safety risk to the 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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/28/2024 01:57 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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited
CCR
87309(a)(1)

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(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.

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Administrator agreed to lock the storage unit and provide photos to the Department by the POC date.
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(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
Based on observation, facility did not comply with section cited above by having an unlocked storage unit located in the back yard which poses a health and safety risk to the residents in care.
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Type B
09/05/2024
Section Cited
CCR87303(a)

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(a) 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.
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Administrator agreed to have areas cleaned, replace toilet tank, and provide photos to the Department by the POC date.
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Based on observation, facility did not comply with section cited above by having toilet tank needs to fit tank, bathtub needs cleaning, kitchen hood needs cleaning, which poses a health and safety risk to the 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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3