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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601363
Report Date: 05/30/2024
Date Signed: 05/30/2024 04:35:28 PM


Document Has Been Signed on 05/30/2024 04:35 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:DIALA, ERICAFACILITY TYPE:
740
ADDRESS:540 PATTERSON BOULEVARDTELEPHONE:
(925) 287-8750
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:75CENSUS: 54DATE:
05/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Erica Diala, AdministratorTIME COMPLETED:
04:45 PM
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On 05/30/2024 at 3:45 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 04/26/2024. LPA met with Administrator, Erica Diala and Director of Resident Services Jonathan Centeno and explained the purpose of the visit.

LPA L. Alexander interviewed S1 regarding the incident that occurred on 04/24/2024 between two (2) residents; R1 and R2. S1 stated that R1 was walking in a room and R2 was walking right behind R1. S1 stated that R2 was pulling on R1 from behind and R1 turned around and pulled a punch onto R2's face. S1 stated that both R1 and R2 fell to the floor and that R2 hit the back of their head on the floor. S1 stated that care staff and med techs came to help get both R1 and R2 off the floor. S1 stated that R1 said that they did not have pain but R2 said that they had pain so they sent R2 to the Emergency Room. S1 stated that R2 returned back to the facility the same day after all exams and testing came back negative.

S1 and S2 stated that both R1 and R2 are ok today and no further issues.

LPA L. Alexander collected documents pertinent to the incident report.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
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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