075601579-8-3-2022-15-AS-JSAR-CGXS5W-20220803133501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601579
Report Date: 08/03/2022
Date Signed: 08/03/2022 01:39:35 PM

Document Has Been Signed on 08/03/2022 01:39 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:	WALNUT CREEK SENIOR LIVING		FACILITY NUMBER:	075601579
ADMINISTRATOR:	DONALD T. HAY		FACILITY TYPE:	740
ADDRESS:	80 CRAGMONT COURT		TELEPHONE:	(925) 939-3635
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	8	CENSUS: 7	DATE:	08/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Donald Hay		TIME COMPLETED:	02:00 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 08/3/22 at 9:15 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry into facility, LPA explained the purpose of the visit. LPA met with and toured the facility with Licensee Donald Hay. Facility has a Covid-19 mitigation plan in place. However, they are not following many aspects of it, including front door signage nor requesting Covid-19 vaccination of visitors. Further, they have not added an infection control plan to their plan of operations as PIN 22-13-ASC - Adult And Senior Care (ASC)- Updated Regulations For Infection Control Requirements requires that they do. The designated infection control leader is the Licensee. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log and a no touch thermometer, hand sanitizer, and face masks. Inside of the facility, some COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. Carbon monoxide and smoke detectors were fully functional and the fire extinguisher had been serviced within one (1) year and it was fully charged. A written Emergency/Disaster plan was posted. Centrally stored medications were in locked cabinets, and sharp objects were stored in locked closets and cabinets. The temperature inside of the facility was 77.4 and the hot water was 105 degrees Fahrenheit, both of which were in the safe range. An administrator is on site more than the required 20 hour minimum each week to oversee business operations. Facility cited with 1 Type A and 2 Type B deficiencies: Continues on 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: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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: WALNUT CREEK SENIOR LIVING	FACILITY NUMBER: 075601579
	VISIT DATE: 08/03/2022

NARRATIVE

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. . . Continued from LIC 809

Physical Plant/Environmental Safety - Type A: 87309(a)(1) - Kitchen cabinets with poisonous cleaning and repair supplies were unlocked. The contents of those cabinets included cooking fuel, mineral spirits, Raid, and cleaning supplies.I
nfection Control Practices - Type B: 87464(f)(1) - No signs were posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic, which was not in accordance with personal rights requirements.
Physical Plant/Environmental Safety - Type B: 87303(i)(1)(B) - Auditory signal device at back door broken.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 08/10/22:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

A total of 3 deficiencies cited during this visit. 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: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/03/2022 01:39 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: WALNUT CREEK SENIOR LIVING	FACILITY NUMBER: 075601579
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 in the kitchen cabinets containing poisonous cleaning and repair supplies that had been left unlocked. The contents of those cabinets included cooking fuel, mineral spirits, Raid, and cleaning supplies, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2022
	Plan of Correction
1 2 3 4	Staff corrected the problem during the visit. Additionally, licensee said that he plans to replace existing locks with magnetic locks to decrease the likelihood of staff leaving them unlocked in the future, as they have already done for the sharps.

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: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/03/2022 01:39 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: WALNUT CREEK SENIOR LIVING	FACILITY NUMBER: 075601579
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87464(f)(1)

Basic Services

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). 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 on the front door where no signs were posted at the facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic, in accordance with personal rights requirements. This practice has a health and safety impact that includes, but is not limited to buildings and grounds, personnel requirements and personal rights, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2022
	Plan of Correction
1 2 3 4	Licensee will send picture proof of Covid-19 signs at the front door to LPA on or before POC due date.

Type B

Section Cited

CCR

87303(i)(1)(B)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. 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 at the back of the facility where the auditory signal device was broken, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2022
	Plan of Correction
1 2 3 4	Staff repaired device during the visit.

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: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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