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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601411
Report Date: 01/18/2023
Date Signed: 01/18/2023 04:34:57 PM


Document Has Been Signed on 01/18/2023 04:34 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MUIR CREEK SENIOR HOMEFACILITY NUMBER:
075601411
ADMINISTRATOR:CARBONEL, LELIA C.FACILITY TYPE:
740
ADDRESS:1066 MUIR CREEK DRIVETELEPHONE:
(925) 427-7049
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 4DATE:
01/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Virginia Cada, CaregiverTIME COMPLETED:
04:45 PM
NARRATIVE
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On 1/18/2023 at 3:15PM, Licensing Program Analysts (LPAs) L. Hall arrived and L. Alexander arrived unannounced to conduct an Infection Control Inspection. LPA met with Virginia Cada, Caregiver and explained the purpose of the visit. Administrator, Lelia Carbonel, arrived at 3:27PM.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 102.8 degrees Fahrenheit. Fire extinguisher last serviced on 1/16/2023. LPAs observed a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the infection control plan on file. LPA observed paper supplies are sufficient.

LPA requested the following documents to be submitted to CCLD by 1/25/2023.
  • Personnel Record (LIC500).
  • Updated emergency disaster plan

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
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 4


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: MUIR CREEK SENIOR HOME
FACILITY NUMBER: 075601411
VISIT DATE: 01/18/2023
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Continued from LIC809.

The following deficiency was observed:

-At 3:50PM, LPAs observed R1 did not have a doctor's order for the hospital bed.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/18/2023 04:34 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: MUIR CREEK SENIOR HOME
FACILITY NUMBER: 075601411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having a doctor's order for R1's hospital bed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2023
Plan of Correction
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Administrator agreed to obtain a copy of a doctor's order for R1's hospital bed and submit a copy to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4