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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601363
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:56:37 PM

Document Has Been Signed on 11/21/2024 12:56 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:MEMORY CARE OF CONTRA COSTAFACILITY NUMBER:
075601363
ADMINISTRATOR/
DIRECTOR:		DIALA, ERICAFACILITY TYPE:
740
ADDRESS:540 PATTERSON BOULEVARDTELEPHONE:
(925) 287-8750
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 75CENSUS: 56DATE:
11/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Erica Diala, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 11/21/2024 at 12:15 pm, Licensing Program Analyst (LPA), L. Alexander arrived unannounced to conduct a case management visit. LPA met with Administrator, Erica Diala and explained the reason for the visit.

While LPA was conducting a complaint investigation, #15-AS-20241120095158, on 11/21/2024, LPA observed during record review and interview with S1 and S2 that they did not submit an incident report to Licensing for incidents including residents' hospitalizations.

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..
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 11/21/2024 12:56 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 11/21/2024 at 12:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MEMORY CARE OF CONTRA COSTA
FACILITY NUMBER: 075601363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2024
Section Cited
CCR
87211(a)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

This requirement is not met as evidenced by:
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Administrator agreed to submit a detailed plan on how they will use proper procedures to inform and notify CCLD and will submit plan to CCLD by POC due date.
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Based on record review and interview with Staff, the licensee did not comply with the section cited above in by not submitting incident reports including but not limited to hospitalizations to Licensing for residents in care which poses a potential health, safety or personal rights risk to persons 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 Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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