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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200030
Report Date: 09/29/2022
Date Signed: 09/29/2022 01:38:52 PM

Document Has Been Signed on 09/29/2022 01:38 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:CROW CANYON RESIDENTIAL CARE IVFACILITY NUMBER:
079200030
ADMINISTRATOR:RUFFY B. YUFACILITY TYPE:
735
ADDRESS:1385 JENSEN DRIVETELEPHONE:
(925) 432-8786
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
09/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Yolanda Vengco, StaffTIME COMPLETED:
01:45 PM
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On 9/29/2022 at 12:30PM Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit to follow-up on a death report received by Community Care licensing. LPA met with Yolanda Vengco and explained the purpose of the visit. Administrator, Ruffy Yu, arrived at 12:58PM

R1 passed away on 9/21/2022 with an unknown cause of death. During today's visit LPA obtained additional information pertaining to R1's death:
  • Hospital discharge summary that includes medications
  • Admission agreement
  • Functional capability
  • Face Sheet
  • Quarterly Report
  • We care skilled nursing dated 6/7/2022

LPA requested from facility a copy of C1's death certificate and the Pittsburg Police Department case number.

LPA was informed by Administrator that C1's death certificate will be provided to
CCLD once available.

No deficiencies cited during this visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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