075601526-4-27-2022-15-AS-JSAR-CDVUYC-20220427155942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601526
Report Date: 04/27/2022
Date Signed: 04/27/2022 04:04:06 PM

Document Has Been Signed on 04/27/2022 04:04 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:	TENDER TOUCH RESIDENTIAL CARE HOME IV		FACILITY NUMBER:	075601526
ADMINISTRATOR:	CRUZ, ESTRELLITA S.		FACILITY TYPE:	740
ADDRESS:	2560 CEDRO PLACE		TELEPHONE:	(925) 954-7242
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 4	DATE:	04/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Gregorio Morales		TIME COMPLETED:	05:30 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 04/27/2022 at 11:30AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA was greeted at the door by S1 who was not wearing a mask. LPA explained the purpose of the visit with S1 and S2. Staff person, Gregorio Morales, arrived at 1:35PM in place of the Licensee who was not able to be at the facility during the inspection. Infection control designated leader is the administrator. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. All staff and 4 clients have been fully vaccinated. Facility has a mitigation plan (LIC 808) in place dated 03/04/2021 to mitigate the spread of COVID-19. LPA discussed the importance of creating an updated infection control plan in accordance with PIN 22-13-ASC with Mr. Morales. LPA inspected the facility inside and outside. LPA observed the 2 staff assisting 4 of the 4 clients with activities of daily living. One central entry point 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 temperature probe. There was at least 7 days of nonperishable and 2 days of perishable foods. Centrally stored medications were locked in the cabinets. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were stored in a locked closet inside the garage. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

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: TENDER TOUCH RESIDENTIAL CARE HOME IV	FACILITY NUMBER: 075601526
	VISIT DATE: 04/27/2022

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/05/2022:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

Facility cited with 1 Type A, a civil penalty of $1,500, and 3 Type B deficiencies.

Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2022 04:04 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: TENDER TOUCH RESIDENTIAL CARE HOME IV	FACILITY NUMBER: 075601526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in all Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. 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 by having too few Covid-19 precautions reminders (social distancing, caugh etiquite, handwashing, and masking) and not having a 30 day supply of PPE at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	Post an additional 10 signs (social distancing, caugh etiquite, handwashing, and masking) throughout the facility and the Licensee shall purchase and store a 30 day supply of PPE adequate for a facility outbreak (facemasks, gowns, surgical masks, N-95s, and at least 2 no-touch lid trash bins). Licensee shall send proof of purchase to LPA by the POC due date.

Type B

Section Cited

CCR

80087(a)

Other Provisions

80087 BUILDINGS AND GROUNDS (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. 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 whereby the kitchen cabinet hinges are very loose which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2022
	Plan of Correction
1 2 3 4	Licensee shall have all of the kitchen cabinet hinges tightened and attest to LPA that task has been completed by the POC 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 04/27/2022 04:04 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: TENDER TOUCH RESIDENTIAL CARE HOME IV	FACILITY NUMBER: 075601526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)(2)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. 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 because there was no emergency food or water in the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	Licensee shall write and prominently post at facility the latest version of the 610E Disaster and Emergency Plan as well as storing at the facility a minimum of 30 gallons of water and at least a 3 day supply of non-perishable food for 10 people and provide proof to LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2022 04:04 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: TENDER TOUCH RESIDENTIAL CARE HOME IV	FACILITY NUMBER: 075601526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(g)

80019 CRIMINAL RECORD CLEARANCE (g) Violation of Section 80019(e) will result in an immediate assessment of a civil penalties of one hundred dollars ($100) per violation per day for a maximum of 5 days by the Department. 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 in 3 out of 3 persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2022
	Plan of Correction
1 2 3 4	Associate S1, S2, and S3 with facility.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC809 (FAS) - (06/04)

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