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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601526
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:59:56 PM


Document Has Been Signed on 07/23/2024 03:59 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 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:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:"Lito" Paquito Balbuena, CaregiverTIME COMPLETED:
04:15 PM
NARRATIVE
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On 7/23/2024 at 3:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection due to a change of ownership. LPA met with caregiver, "Lito" Paquito Balbuena and explained the purpose of the visit. Licensee/Applicant, Claro Villanueva arrived an hour later. Licensee/Applicant was unable to stay to sign the reports and designated caregiver, "Lito" Paquito Balbuena to sign the reports.

During Pre-licensing Inspection, LPA observed the following deficiencies:

At 11:00AM, LPA observed unlocked laundry detergents in the bathroom, unlocked cleaning supplies in the kitchen area, and unlocked wood paint in the cabinets. Staff locked up laundry detergents, cleaning supplies, and wood paint during inspection.

At 11:15AM, LPA observed unlocked medications in the main refrigerator. Staff locked up the medications in the locked refrigerator during inspection.

At 11:40AM, LPA observed the pool gate was not locked. Staff put a lock on the pool gate during inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.



Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 07/23/2024 03:59 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: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
87309(a)

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Storage Space. Disinfectants, cleaning solutions...and other items which could pose a danger ...shall be stored where inaccessible to clients.
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Staff locked up the detergents, cleaning supplies, and paints during inspection.

Deficiency cleared.
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This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by having detergents, cleaning supplies, and paints unlocked which poses an immediate health and safety risk to the persons in care.
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Type A
07/24/2024
Section Cited
CCR87465(h)(2)

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Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible...This requirement is not met as evidence by:
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Staff locked up the medications during inspection.

Deficiency cleared.
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 Based on observation, licensee did not comply with the section cited above by having unlocked medications in the refrigerator which poses an immediate health and safety risk to the persons in care.
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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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/23/2024 03:59 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: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
87307(e)

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Personal Accommodations and Services. Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of ...swimming pools...
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Staff put a lock on the pool gate during inspection.

Deficiency cleared.
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This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by not having a lock on one of the pool gate which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $500 is being assessed.

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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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3