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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601489
Report Date:
02/14/2023
Date Signed:
02/14/2023 03:41:20 PM
Document Has Been Signed on
02/14/2023 03:41 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 I
FACILITY NUMBER:
075601489
ADMINISTRATOR:
BRAGG, JILL L.
FACILITY TYPE:
740
ADDRESS:
123 LOS CERROS AVENUE
TELEPHONE:
(925) 944-5363
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94598
CAPACITY:
6
CENSUS:
6
DATE:
02/14/2023
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
03:15 PM
MET WITH:
Jill Bragg
TIME COMPLETED:
03:50 PM
NARRATIVE
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This is a continuation of the original inspection to include citation. (Refer to LIC 808D.
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
James Sampair
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/14/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2023
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
2
Document Has Been Signed on
02/14/2023 03:41 PM
- It Cannot Be Edited
Created By:
James Sampair
On
02/14/2023
at
03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
DIABLO ASSISTED LIVING I
FACILITY NUMBER:
075601489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/14/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
(a) Residents in all residential care facilities for the elderly shall have all of the personal rights: (2) To be accorded safe, healthful and comfortable accomodations, furnishings and equipment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 staff members they were not wearing face coverings, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/15/2023
Plan of Correction
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2
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4
Citation cleared during inspection.
Section Cited
Deficient Practice Statement
1
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 Humpal
LICENSING EVALUATOR NAME:
James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE:
02/14/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2023
LIC809
(FAS) - (06/04)
Page:
2
of
2