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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601489
Report Date: 09/08/2022
Date Signed: 09/08/2022 06:19:08 PM


Document Has Been Signed on 09/08/2022 06:19 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:DIABLO ASSISTED LIVING IFACILITY NUMBER:
075601489
ADMINISTRATOR:BRAGG, JILL L.FACILITY TYPE:
740
ADDRESS:123 LOS CERROS AVENUETELEPHONE:
(925) 944-5363
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jill BraggTIME COMPLETED:
05:30 PM
NARRATIVE
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On 9/8/22 at 2:00 PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit. Licensee Jill Bragg toured the facility inside and outside with LPA.

Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing. The temperature inside of the facility was 82.2 and the hot water was 108 degrees Fahrenheit, both of which were in the safe range. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

Facility cited for 4 Type B deficiencies (refer to LIC 809-D). Facility cited for carbon monoxide detector not connected. Quarterly fire drills not being conducted annually. Fire extinguisher was fully charged, but had not been recharged within the past year. Resident chair blocking emergency exit from bedroom with reclining chair.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/15/22:

· LIC500 - Personnel Report
· Evidence of Liability Insurance

Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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


Document Has Been Signed on 09/08/2022 06:19 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: DIABLO ASSISTED LIVING I
FACILITY NUMBER: 075601489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 1 out of 1 detectors, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Licensee made correction during inspection.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 #4 where the resident's reclining chair was blocking the emergency exit through the sliding glass door to the outside, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Exit to the outside in bedroom #4 shall be cleared and proof sent to LPA on or before the 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/08/2022 06:19 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: DIABLO ASSISTED LIVING I
FACILITY NUMBER: 075601489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not conducting quarterly emergency drills in 2020, 2021, and 2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Staff will conduct next emergency drill before due date and provide picture of drill report to LPA.
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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 2 out of the 2 fire extinguishers that had not been recharged within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Recharge fire extinguishers and provide proof to LPA on or before 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3