075601332-5-3-2023-15-AS-LAWN-CRH3RB-20230503182828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601332
Report Date: 05/03/2023
Date Signed: 05/03/2023 06:32:17 PM

Document Has Been Signed on 05/03/2023 06:32 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	BOYD SENIOR CARE HOME		FACILITY NUMBER:	075601332
ADMINISTRATOR:	PERDIGUERRA, LILIA		FACILITY TYPE:	740
ADDRESS:	345 BOYD ROAD		TELEPHONE:	(925) 256-6500
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 4	DATE:	05/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Lilia Perdiguerra, Licensee		TIME COMPLETED:	06:40 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 05/03/2023 starting 1:09 PM, Licensing Program Analyst (LPAs) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee, Lilia Perdiguerra and explained the purpose of the visit. The facility’s fire clearance was approved for all six (6) non-ambulatory residents. There were 2 staff and 4 residents present during inspection. Starting at 1:20 PM, LPA toured facility with Licensee and Administrator, Jerry Perdiguerra including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are for residents and 1 bedroom is for staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in residents’ shared bathroom was measured at 110.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 10/13/2022. First aid kit was observed to be complete. REPORT CONTINUES ON LIC809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
	VISIT DATE: 05/03/2023

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
26
27
28
29
30
31
32

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 1:20 PM, LPA observed medication pill bottle located in kitchen cabinet
vitamins
At 1:21 PM, LPA observed multi surface cleaner spray, Raid Ant Spray, kitchen degreaser located under sink
At 1:22 PM, LPA observed scissors, knives and other sharps located in kitchen cabinet
At 1:24 PM, LPA observed disinfectant spray and Clorox Wipes located in Bedroom# 2 bathroom under sink
At 1:27 PM, LPA observed disinfectant spray, Tide Liquid Laundry Detergent, Clorox Bleach in cabinets in laundry area
At 2:30 PM, LPA observed that R1 in Bedroom# 1 has oxygen sign on door, but no "Oxygen in Use" posted on the front door outside
At 2:35 PM, LPA observed shovel, wheel barrel, ladders located in backyard unlocked
At 2:37 PM, LPA observed tools: hammers, saws, gardening tools in shed unlocked
At 2:50 PM, LPA observed during record review that R4 who is bedridden in Bedroom#3 has no Fire Clearance
At 3:16 PM, LPA observed no staff records available during record review

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.

LPA will return at a later time to complete the inspection.

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 05/03/2023 06:32 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above by not having a fire clearance for R4 which poses an immediate health and safety to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Administrator will submit a LIC 200 and a copy of floor plan or re-locate the resident by POC due date. A $500 Civil Penalty is being assessed.

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 05/03/2023 06:32 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

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 by not having knives, scissors and sharps inaccessible to residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Administrator locked up all sharps during visit. Administrator ordered safety locks during visit and will send photos with new locks by POC due date. Deficiency cleared.

Type A

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 by not having medications, vitamins, disinfectant spray, Raid Spray, Tide Laundry Detergent, Clorox Bleach, shovel, ladders, wheel barrels inaccessible which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Administrator locked up medications, vitamins, disinfectant spray, Clorox Bleach, Tide Laundry Detergent, ladders, shovels, wheel barrels during visit. Deficiency cleared.

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 Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 05/03/2023 06:32 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(g)

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not maintaining records at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Administrator will get ALL staff records and send a photo to CCLD by POC due 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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5