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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601526
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:56:18 PM


Document Has Been Signed on 04/23/2024 03:56 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:TENDER TOUCH RESIDENTIAL CARE HOME IVFACILITY NUMBER:
075601526
ADMINISTRATOR:CRUZ, ESTRELLITA S.FACILITY TYPE:
740
ADDRESS:2560 CEDRO PLACETELEPHONE:
(925) 954-7242
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Claro VillanuevaTIME COMPLETED:
04:15 PM
NARRATIVE
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On 4/23/2024 at 1:15 PM, Licensing Program Analysts (LPAs) J. Sampair and A. Gharachorloo arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPAs stated the purpose of the visit to Caregiver Paquito Balbuena. Administrator Claro Villanueva arrived at approximately 2:30 PM.

LPAs inspected the interior and exterior of the facility, including the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the living room was measured at 75.8 degrees Fahrenheit at 3:06 PM. Fire extinguisher was fully charged.

The carbon monoxide and smoke detector were fully operational. The LPAs observed postings in the facility that included a complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council, and Rights to Family Council.

An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPAs reviewed facility records, records of 5 staff members, and records of 5 residents. The LPAs interviewed 2 staff members and 2 residents.

3 Type-B citations issued (refer to LIC809D).

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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 04/23/2024 03:56 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: TENDER TOUCH RESIDENTIAL CARE HOME IV
FACILITY NUMBER: 075601526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.627(i)
Other Provisions
(i) Changes in condition, including, but not limited to, when and under what circumstances are changes made to a participant's care plan.

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 in 4 out of 6 resident files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Licensee shall complete LIC 625 Appraisal / Needs and Services plans for the 4 residents where that is missing on or before the due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 the kitchen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Licensee shall repair the broken cabinets and clean all of the greasy surfaces in the kitchen 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) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/23/2024 03:56 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: TENDER TOUCH RESIDENTIAL CARE HOME IV
FACILITY NUMBER: 075601526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 in 5 out of 5 staff training records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Licensee shall ensure that all staff complete a minimum of 20 hours of training on or before the due date.
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) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3