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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601447
Report Date: 09/17/2021
Date Signed: 09/17/2021 04:49:21 PM

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:LAFAYETTE RESIDENTIAL CAREFACILITY NUMBER:
075601447
ADMINISTRATOR:OPHELIA PEDROSOFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 3DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Virgillo Tambalo, CaregiverTIME COMPLETED:
05:00 PM
NARRATIVE
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On 9/17/2021 at 1:55PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Virgillo Tambalo, Caregiver. LPA spoke with Administrator, Ophelia Pedroso via telephone and explained the reason for the visit. Administrator gave approval for Caregiver to sign documents.

LPA was informed that Licensee no longer has control of property. LPA spoke with Licensee and was advised that there is a lease back agreement and it will be submitted to CCLD by 09/20/2021. It appears an application was submitted for a new license, however, until the new license is approved no changes to property should be made. Licensee will keep CCLD informed with any updates.

Upon entry, LPA observed hand sanitizer and COVID-19 signs were posted at the screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, backyard, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap paper towel, and hand washing signs were posted.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file.

LPA requested a copy of the facility roster and LIC500 to be submitted to CCLD by 09/24/2021.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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 8
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
VISIT DATE: 09/17/2021
NARRATIVE
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Continued from LIC9099.

-Approximately at 1:55pm, symptoms check was not initiated at entrance. LPA was not screed for COVID-19 symptoms and LPA's temperature was not checked.

-Approximately at 2:30pm, LPA observed closet door in bedroom #5 to be off track.

-Approximately at 2:35pm, LPA observed renovation being done in the backyard. There was backhoe, hatchet, 2 shovels, an axe, saw, rake, table saw, 3 wheel barrows with yard debris and 2 ladders. The fence is leaning and has missing planks and the storage shed was not locked.

-Approximately 2:38pm, LPA observed a hospital bed, chair, and lamp located on the right side of the house obstructing the emergency exit.

-Approximately 2:45pm, LPA observed facility did not have limited PPE.

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional 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: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 6 of 8
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of persons with dementia (f)The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 in tools being accessible and a backhoe tractor in backyard, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2021
Plan of Correction
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Administrator agreed to have all tools made inaccessible, backhoe to be removed, and shed locked. A copy of pictures will be submitted to CCLD by POC date.
Section Cited
Deficient Practice Statement
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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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 7 of 8
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and operation a) 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 in bedroom #5 the closet door was off track, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2021
Plan of Correction
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Administrator agreed to have closet door fixed and put back on track, and submit a photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
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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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 8 of 8