075601315-5-23-2022-15-AS-LFII-CEPUQH-20220523154710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601315
Report Date: 05/23/2022
Date Signed: 05/23/2022 03:48:18 PM

Document Has Been Signed on 05/23/2022 03:48 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:	BLACKHAWK SENIOR RESIDENTIAL CARE		FACILITY NUMBER:	075601315
ADMINISTRATOR:	PETITI, NORA		FACILITY TYPE:	740
ADDRESS:	209 FARM HILL COURT		TELEPHONE:	(925) 820-8783
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	6	CENSUS: 4	DATE:	05/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Nora Petiti- Administrator		TIME COMPLETED:	04:00 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 5/23/2022 at 1:25pm, Licensing Program Analyst (LPA) L. Fici & L. Francisco arrived unannounced to conduct an annual Infection Control Inspection. LPAs met with Licensee, Nora Petiti and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility with Nora Petiti (administrator) including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable 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 sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Continue on LIC809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

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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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: BLACKHAWK SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 075601315
	VISIT DATE: 05/23/2022

NARRATIVE

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At 1:55pm, during record review, LPAs reviewed four (4) staff records and two (2) residents records. 4 of 4 staff have health screening and TB tests on file. 2 of 2 residents does not have current medical assessment and needs and services plan.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:

At approx. 1:40pm, LPAs observed pad lock attached on the gate to the pool was unlocked Deficiency cleared during visit. LPAs observed Administrator lock the gate to the pool.
At 2:00pm, during record review, LPAs observed S1 was not fingerprint cleared (Deficiency cleared during visit). LPAs observed S1 leave the facility.
at 2:10pm, during record review, LPAs observed R1 and R2 does not have current medical assessment and needs and services plan.

The following forms are to be updated and submitted to CCLD By 6/8/2022.

LIC500- Personnel Report
LIC308- Designation of Administrative Responsibility
LIC610E - Emergency Disaster Plan
An updated copy of Administrator certificate
Liability Insurance

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

An immediate civil penalties of $1,000 is being assessed

Exit interview conducted and a copy of this report provided along with appeal right.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2022 03:48 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: BLACKHAWK SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 075601315
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87308(c)

Resident and Support Services

(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. 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. LPAs observed pad lock attached on the gate to the pool was unlocked which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/24/2022
	Plan of Correction
1 2 3 4	Deficiency cleared during visit; LPAs observed ADM lock the gate to the pool. In addition administartor will review regulation and conduct in service training with staff and submit a copy of training with staff signatures to CCLD by 6/3/2022. $500 Civil penalty is being assessed.

Type A

Section Cited

CCR

87355(e)(1)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPAs observed S1 is not fingerprint cleared, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/24/2022
	Plan of Correction
1 2 3 4	Deficiency cleared during visit. LPAs observed S1 leave facility; In addition administartor will review regulation and conduct in service training with staff and submit a copy of training with staff signatures to CCLD by 6/3/2022. $500 Civil penalty is being assessed.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/23/2022 03:48 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: BLACKHAWK SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 075601315
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPAs observed R1 and R2 did not have updated medical assessment and needs and services plan which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Licensee agrees review regulation and submit a copy of R1 and R2's medical aseessment and needs and services to CCLD by POC 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC809 (FAS) - (06/04)

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