079200132-9-29-2023-15-AS-LHAL-CW5RJC-20230929130344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200132
Report Date: 09/29/2023
Date Signed: 09/29/2023 01:03:55 PM

Document Has Been Signed on 09/29/2023 01:03 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 CARE HOME		FACILITY NUMBER:	079200132
ADMINISTRATOR:	LINDA PENANO		FACILITY TYPE:	735
ADDRESS:	47 OXFORD COURT		TELEPHONE:	(925) 427-6925
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY: 6		CENSUS: 6	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Josephine Sawyer, Caregiver		TIME COMPLETED:	01:10 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 9/29/2023 at 10:50am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Josephine Sawyer, Caregiver, and explained the purpose of the visit. Administrator, LInda Penano, arrived at 11:30am. Facilities fire clearance is for six (6) ambulatory clients. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms. One (1) bedroom occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 119.3 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke detectors/carbon monoxide were in operating condition during visit. Emergency disaster plan updated 2/15/2021. Fire extinguisher was last services on 3/8/2023. Fire drill last conducted 9/4/2023. First aid kit was observed to be complete. Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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

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: CROW CANYON CARE HOME	FACILITY NUMBER: 079200132
	VISIT DATE: 09/29/2023

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
26
27
28
29
30
31
32

Continued from LIC809.

Three (3) staff records were reviewed, and all staff have first aid certification. All six (6) clients' records reviewed, current, and complete. LPA reviewed P&I.

The following forms to be updated and submitted to CCLD by 10/6/2023:

Liability insurance.
Surety Bond
LIC500 (Personnel Record)
Client Roster
LIC308 (Designation of facility Responsibility)
LIC 400 Affidavit Regarding Client/Resident Cash Resources
Emergency Disaster Plan (9 pages)

LPA observed the follow deficiency:

At 12:25pm, LPA observed a wall built that separates the garage into two (2) rooms.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (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. A copy of the appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/29/2023 01:03 PM - It Cannot Be Edited

Created By: Laura Hall On 09/29/2023 at 12:52 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 CARE HOME	FACILITY NUMBER: 079200132
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80086(b)

80086 Alterations to Existing Building or New Facilities (b) The licensing agency shall have the authority to require that the licensee have a building inspection by a local building inspector if the agency suspects that a hazard to the clients' health and safety exists. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having a new facility sketch and permit for wall built in garage which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit new facility sketch and LIC200 to CCLD by POC date.

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

LICENSING EVALUATOR NAME:

Laura Hall

LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3