075601315-12-20-2023-15-AS-AGOZ-CYPSEY-20231220124930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601315
Report Date: 12/20/2023
Date Signed: 12/20/2023 12:49:40 PM

Document Has Been Signed on 12/20/2023 12:49 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:	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: 3	DATE:	12/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Adoracion De Leon		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) A. Gomez conducted an unannounced 1 Year annual inspection on this date at 9:00am. LPA met with Administrator, Adoracion De Leon and Licensee, Nora Petiti. The facility’s fire clearance was approved for all may be non-ambulatory and subject to five hospice waivers. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. Swimming pool is locked and fenced. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 6/23/2021 . Emergency Disaster Plan was last posted on 12/20/2023 . First aid kit was observed to be complete. Fire drill was last conducted on 10/30/2023. LPA reviewed four staff files and 4 of 4 staff are associated to the facility and have current first aid certificate. LPA reviewed three residents records. Report continues on 809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLACKHAWK SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 075601315
	VISIT DATE: 12/20/2023

NARRATIVE

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The Following Deficiencies were observed:

11:21am unlocked knives, scissors, and box cutter. Administrator locked away during visit.
11:21am unlocked laxatives. Administrator locked away during visit.
11:50am Fire extinguisher dated 6/23/2021 (expired)

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/31/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

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

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2023 12:49 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: BLACKHAWK SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 075601315
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 having unlocked sharps which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/21/2023
	Plan of Correction
1 2 3 4	Administrator locked away all sharps during visit.

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) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 12/20/2023 12:49 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: BLACKHAWK SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 075601315
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 having unlocked laxatives which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/21/2023
	Plan of Correction
1 2 3 4	Administrator locked away all laxatives.

Type B

Section Cited

CCR

87203

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 fire extinguisher not have being serviced in over 12 months which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2023
	Plan of Correction
1 2 3 4	By POC date administrator agrees to buy new fire extinguishers and submit photographic proof to CCLD.

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) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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