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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200290
Report Date: 08/18/2022
Date Signed: 08/18/2022 01:18:45 PM


Document Has Been Signed on 08/18/2022 01:18 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:A PLACE FOR SENIORS, LLCFACILITY NUMBER:
079200290
ADMINISTRATOR:DISTEFANO, KAMILLAFACILITY TYPE:
740
ADDRESS:257 NORMANDY LANETELEPHONE:
(925) 516-6665
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kamilla DistefanoTIME COMPLETED:
01:30 PM
NARRATIVE
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On 8/18/22 at 9:45 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit with Licensee / Administrator Kamilla Rani Distafano who toured the facility inside and outside with the LPA.

Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. 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, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing.

A written Emergency/Disaster plan was posted. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 75.7 and the hot water was 120 degrees Fahrenheit, both of which were in the safe range.

However, toxic chemicals, over-the-counter medications, and sharp objects were left accessible to the residents, for which the facility was cited (refer to LIC 809-D).

Carbon monoxide and smoke detectors were functional and the fire extinguisher had been serviced within one (1) year and it was fully charged. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

Continues on LIC 809-C . . .
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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 5


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: A PLACE FOR SENIORS, LLC
FACILITY NUMBER: 079200290
VISIT DATE: 08/18/2022
NARRATIVE
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. . . Continued from LIC 809

Facility given a Technical Violation and then cited with 3 Type A deficiencies, all of which they corrected during the visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 08/18/2022 01:18 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: A PLACE FOR SENIORS, LLC
FACILITY NUMBER: 079200290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because of the cleaning solutions that were in an unlocked cabinet under sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2022
Plan of Correction
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Licensee corrected deficiency during visit.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above where knives were in an unlocked drawer, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2022
Plan of Correction
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Licensee corrected deficiency during 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 08/18/2022 01:18 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: A PLACE FOR SENIORS, LLC
FACILITY NUMBER: 079200290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when a bottle of Miralax was left in an unlocked cabinet accessible to the residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2022
Plan of Correction
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Licensee corrected deficiency during visit.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5