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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601447
Report Date: 12/16/2021
Date Signed: 12/16/2021 02:53:42 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:
12/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Ophelia Pedroso, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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On 12/16/2021 at 9:05AM, Licensing Program Analysts (LPAs) C. Lin and L. Hall arrived unannounced to conduct Changing Ownership Pre-licensing Required inspection. LPAs met with Administrator Ophelia Perdroso and explained the purpose of the visit. The facility currently has 3 residents. Applicants Phillip and Tamra McGill arrived later.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· At 10:40AM, LPA observed 3 residents' files were incomplete.
· At 11:10AM, LPA observed chemical supplies were accessible to residents.

The following 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. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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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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: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited

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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)
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Based on observation, the licensee did not comply with the section cited above where chemical supplies in the garage were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
12/24/2021
Section Cited

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Based on record review, the licensee did not comply with the section cited above where residents' files were incomplete which poses a potential health, safety or personal rights risk to persons in care.
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021
LIC809 (FAS) - (06/04)
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