075601363-1-29-2025-15-AS-LAWN-DDE5EU-20250129185407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601363
Report Date: 01/29/2025
Date Signed: 01/29/2025 06:56:17 PM

Document Has Been Signed on 01/29/2025 06:56 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 COSTA		FACILITY NUMBER:	075601363
ADMINISTRATOR/ DIRECTOR:	DIALA, ERICA		FACILITY TYPE:	740
ADDRESS:	540 PATTERSON BOULEVARD		TELEPHONE:	(925) 287-8750
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY: 75	TOTAL ENROLLED CHILDREN: 0	CENSUS: 58	DATE:	01/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Erica Diala, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	07:15 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 01/29/2025 at 11:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Erica Diala and explained the purpose of the visit. The facility’s fire clearance was approved for capacity 75 non-ambulatory. Hospice waiver for Nineteen (19) residents. Administrator Certificate #6069844740 expires 05/08/2026. LPA toured the facility with Erica including but not limited to five (5) residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 and 74 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 105 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. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed thirteen (13) residents records. LPA reviewed sixteen (16) staff records and fourteen (14) of sixteen (16) have current first aid training and associated to the facility. LIC809 Continued....

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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 01/29/2025 06:56 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: MEMORY CARE OF CONTRA COSTA	FACILITY NUMBER: 075601363
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation an drecord review, the licensee did not comply with the section cited above in by not having S1 associated through Guardian which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Administrator associated Staff during visit. Deficiency cleared 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/29/2025 06:56 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: MEMORY CARE OF CONTRA COSTA	FACILITY NUMBER: 075601363
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(h)

87463 Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having an updated annual medical assessment for R1-R4 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit updated LIC 602-A for R1-R4 to CCLD by POC due date.

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having updated First Aid/CPR certifiications for S2 and S3 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/26/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit First Aid/CPR certificates for S1 and S2 to CCLD by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/29/2025 06:56 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: MEMORY CARE OF CONTRA COSTA	FACILITY NUMBER: 075601363
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87555(b)(15)

87555 General Food Service Requirements b) The following food service requirements shall apply: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having current Food Handler Certifications for S4 and S5 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit updated food handler certificates for S3 and S4 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

Page: 4 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: MEMORY CARE OF CONTRA COSTA	FACILITY NUMBER: 075601363
	VISIT DATE: 01/29/2025

NARRATIVE

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LIC809-C Continued...

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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/05/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (All 9 pages)
Liability Insurance

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: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

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