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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601315
Report Date: 04/05/2024
Date Signed: 04/05/2024 01:32:57 PM


Document Has Been Signed on 04/05/2024 01:32 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 CAREFACILITY NUMBER:
075601315
ADMINISTRATOR:PETITI, NORAFACILITY TYPE:
740
ADDRESS:209 FARM HILL COURTTELEPHONE:
(925) 820-8783
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 3DATE:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Adoracion De LeonTIME COMPLETED:
01:50 PM
NARRATIVE
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On 4/5/2024 at 10:00 AM Licensing Program Analysts (LPAs) A. Gomez and A. Gharchorloo conducted an unannounced 1 Year annual inspection. LPAs 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.

LPAs 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 105.1 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 12/24/2023 . Emergency Disaster Plan was last posted on 12/21/2023 . First aid kit was observed to be complete. Fire drill was last conducted on 10/30/2023.

LPA reviewed two staff files and 2 of 2 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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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 4


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: 04/05/2024
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 10:30AM during file review LPAs observed that the disaster drills are not up to date
  • At 11:21AM during tour LPAs observed an unlocked lighter in kitchen drawer, a black pair of kitchen scissors in an unlocked drawer, and medication cabinet unlocked with residents medication. Administrator locked everything away. Deficiency Cleared. Repeat Violation 87705(f)(1) ($250)
  • At 11:32AM during tour LPAs observed R1's room missing the appropriate oxygen in use sign.
  • At 11: 40AM during tour LPAs observed the pool unlocked. Pool had pad lock attached but lock was not fully latched to lock position. Administrator Locked pool during the visit. Deficiency cleared. Immediate Civil Penalty ($500)

***An Immediate civil penalty of $500 is being assesed today for having an unlocked pool***

***A civil penalty of $250 is being assessed today for a repeat violation in a 12 month period****


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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/05/2024 01:32 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: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having the pool unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2024
Plan of Correction
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Administrator locked the pool.
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
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Based on observation, the licensee did not comply with the section cited above in having dangerous items unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2024
Plan of Correction
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Administrator locked away all of the dangerous items.
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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/05/2024 01:32 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: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above innot having an updated drill done which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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By POC date Administrator agrees to conduct drills and update the log and notify CCLD
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having the appropriate sign posted which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2024
Plan of Correction
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By POC date Administrator agrees to post the appropriate sign and notify 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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4