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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601406
Report Date: 11/12/2021
Date Signed: 11/15/2021 08:46:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LA CASA VERDEFACILITY NUMBER:
075601406
ADMINISTRATOR:ALCANTARA, LEONARDOFACILITY TYPE:
740
ADDRESS:1405 CAMINO VERDETELEPHONE:
(925) 285-5078
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:6CENSUS: 3DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Leonardo AlcantaraTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection of the facility. Upon entry into the facility, The LPA explained the purpose of the visit with Licensee and designated Infection control leader Leonardo Alcantara, who toured the inside and outside with the LPA. The LPA observed that 1 of 2 staff members were wearing facial covering. Otherwise, they followed all of the required steps necessary for visitors to control infections including asking for vaccination status and the use of a screening station near the entrance. COVID-19 signs were posted in common areas to promote hand washing and physical distancing. Staff are documenting temperature and health status of staff and residents on a daily basis. Mr. Alcantara reported that all staff and residents were fully vaccinated, including their boosters.

The LPA inspected the facility inside and outside. The Licensees were providing appropriate care for the residents in a well maintained and safe environment for the most part. The LPA observed that the temperature within the facility was maintained at a comfortable temperature. However, the hot water that was at 130 degrees Fahrenheit, for which the Licensees were cited Type A violation because it was outside of the 105 to 120 degree range in Title 22 Section 87303(e)(2). There were sufficient food and water supplies, which were appropriately labelled. However, in the back yard there was a great deal of junk that needed to be removed, for which the facility was cited a Type B violation according to Section 87303(a). The Smoke and Carbon monoxide detectors were fully operational. and the fire extinguisher was fully charged and last replaced February of 2021.

The facility was cited for 1 Type A and 1 Type B deficiencies, the details of which are in the LIC809-D.

An exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LA CASA VERDE
FACILITY NUMBER: 075601406
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 due to the water temperature being 130 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2021
Plan of Correction
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Reduce water temperature and provide photo proof to the LPA by due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LA CASA VERDE
FACILITY NUMBER: 075601406
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 due to the back yard junk in back yard, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2021
Plan of Correction
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junk in back yard needs to be cleared and photo proof sent to LPA
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3