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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200290
Report Date: 10/06/2023
Date Signed: 10/06/2023 12:35:58 PM


Document Has Been Signed on 10/06/2023 12:35 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
OAKLAND ASC, 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:
10/06/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Kamilla DiStefanoTIME COMPLETED:
12:45 PM
NARRATIVE
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On 10/06/2023 at 09:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for a Case Management visit concerning the request by Licensee to increase the capacity from 6 to 7 residents. LPA stated the purpose of the visit to Caregiver Michelle Boyer upon entering the facility. Licensee Kamilla DiStefano arrived at approximately 10:30 AM.

LPA reviewed the floor plan facility sketch during his tour of the facility inside and outside. The sketch is inaccurate and it will need to be rewritten and pass re-inspection by LPA before submission to the Fire Marshall to complete a new Fire Safety Inspection.

3 Type-B citations issued during inspection (refer to LIC809-D for details).

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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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 10/06/2023 12:35 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
OAKLAND ASC, 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: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2023
Section Cited
CCR
87705(h)

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87705 CARE OF PERSONS WITH DEMENTIA (h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
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On or before due date, Licensee shall send LPA photo proof and statement attesting to the fully operating gate.
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Based on observation, the side gate latch and self-closing hinge are not working, which poses a potential threat to the health, safety, and personal rights of the residents.
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Type B
10/13/2023
Section Cited
CCR87307(d)(6)

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87307(d)(6) Personal Accommodations and Services (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
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Licensee corrected citation during inspection.
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Based on observation, the sliding glass door to the deck was blocked by furniture, which posed a potential threat to the health, safety, and personal rights of the residents.
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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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/06/2023 12:35 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
OAKLAND ASC, 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: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2023
Section Cited
CCR
87307(d)(2)

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87307(d)(2) Personal Accommodations and Services (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
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On or before the due date, the Licensee shall send photo proof and attest to the LPA of the full functioning of the door handles in that bathroom.
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Based on observation, the doors in bathroom next to bedroom #6 are not operating correctly, which pose a potential threat to the health, safety, and personal rights of the residents.
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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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
LIC809 (FAS) - (06/04)
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