075601489-12-3-2024-15-AS-DDOE-DBLSEC-20241203124831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601489
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:52:17 PM

Document Has Been Signed on 12/03/2024 12:52 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	DIABLO ASSISTED LIVING I		FACILITY NUMBER:	075601489
ADMINISTRATOR/ DIRECTOR:	BRAGG, JILL L.		FACILITY TYPE:	740
ADDRESS:	123 LOS CERROS AVENUE		TELEPHONE:	(925) 357-8124
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Applicants Ninia Villanueva and Maricel Evangelista		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/03/2024 at 8:30 AM, Licensing Program Analysts (LPAs) James Sampair and David Doidge arrived unannounced to conduct a annual inspection. Upon entry into the facility, the LPAs informed Applicants Ninia Villanueva and Maricel Evangelista of the purpose of the visit. The LPAs toured the facility inside and outside. The LPAs inspected the kitchen, common areas, bedrooms, bathrooms, and the exterior of the facility. The facility was clean, appropriately furnished, and well lit. More than the 2 days of perishable and 7 days of nonperishable food supplies were available. No body of water was on the facility grounds. Medications are centrally stored. Bathrooms and showers were observed to be fully functioning and clean. The hot water temperature in the bathroom was 110 degrees. The room temperature of the living room was 71 degrees. Carbon monoxide and smoke detectors were operational. The fire extinguisher was last serviced on 09/25/2024. Facility has emergency lighting. LPA s review six (6) resident records and five (5) staff records. All were complete. The LPAs observed required postings in the facility, including the Residential Care Facility for the Elderly Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. Toxins and sharp objects were locked and inaccessible to participants. Conitnued on LIC809-C.

Bennett Fong	TELEPHONE: (510) 286-4201
David Doidge	TELEPHONE: (916) 475-5913
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DIABLO ASSISTED LIVING I	FACILITY NUMBER: 075601489
	VISIT DATE: 12/03/2024

NARRATIVE

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Continued from LIC809

LPA requested the following documents to be submitted to CCLD by 12/10/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted and a copy of this report provided to the Applicant

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2024 12:52 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DIABLO ASSISTED LIVING I	FACILITY NUMBER: 075601489
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above first-aid kit is mssing an instruction manual which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Administrator has purchased a first-aid manual. Cleared during visit.

Section Cited

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as fire drills had not been conducted which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Administrator conducted a fire drill during visit. POC cleared..

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) 286-4201
David Doidge	TELEPHONE: (916) 475-5913
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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