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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200030
Report Date: 07/06/2022
Date Signed: 07/06/2022 05:05:08 PM

Document Has Been Signed on 07/06/2022 05:05 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:
07/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Ruffy Yu, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 07/06/22, LPA D Panlilio conducted a subsequent visit to amend the complaint report dated 04/28/22. LPA explained the purpose of the visit with administrator.

This is in reference to COMPLAINT CONTROL NUMBER: 15-AS-20211228104311.
The allegation was that client sustained multiple pressure injuries while in care at the facility. Upon further review of information gathered during investigation, the complaint investigation finding was amended from unsubstantiated to substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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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Document Has Been Signed on 07/06/2022 05:05 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 07/06/2022 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CROW CANYON RESIDENTIAL CARE IV
FACILITY NUMBER: 079200030

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2022
Section Cited
CCR
80078(a)

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Responsibility for Providing Care & Supervision
The licensee shall provide care and supervision as necessary to meet the client's needs.
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Immediate civil penalty of $500 assessed during visit.

By POC due date, Administrator agreed to submit to CCLD a copy of completed staff in-service retraining
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This requirement was not met as evidenced by client sustaining multiple pressure injuries while in care which posed an immediate health & safety risk to client in care
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regarding timely addressing client's change in condition for immediate treatment and evaluation by the primary care physician.

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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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


LIC809 (FAS) - (06/04)
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