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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601498
Report Date: 04/20/2022
Date Signed: 04/21/2022 08:18:31 AM


Document Has Been Signed on 04/21/2022 08:18 AM - 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 IIFACILITY NUMBER:
075601498
ADMINISTRATOR:BRAGG, JILL L.FACILITY TYPE:
740
ADDRESS:15 GLENCREEK LANETELEPHONE:
(925) 915-0825
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 5DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jill BraggTIME COMPLETED:
02:30 PM
NARRATIVE
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On 04/20/2022 at 12::00 PM, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced infection control and required one year inspection. Upon arrival, LPA explained the purpose of the visit to Licensee Jill Bragg who led a tour of the facility inside and outside.

They are following their COVID-19 mitigation planning closely. The LPA observed staff wearing face masks, screening checks with a no-touch temperature probe and the use of a visitor's log, and hand sanitizer, gloves, and face masks for visitors. LPA observed COVID-19 signs posted in common areas to promote hand washing, cough/sneeze etiquette, and physical distancing. In the facility, staff check and log temperatures and COVID-19 symptom checks daily and log that data daily.

During the visit, pathways were observed to be free of obstruction and fire hazards. Last Fire drill was conducted February of 2022.. Facility room temperature was maintained at a comfortable 72.3 degrees Fahrenheit and the hot water temperature was 120 degrees Fahrenheit.

The facility was cited for a Type A deficiency because of the two non-functioning door alarms.

Exit interview conducted and a copy of this report was provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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 2


Document Has Been Signed on 04/21/2022 08:18 AM - 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 II
FACILITY NUMBER: 075601498

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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 because two of the door alarms were not working which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Repair of non-functioning door alarms was completed during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2