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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200377
Report Date: 09/28/2022
Date Signed: 09/28/2022 11:34:59 AM

Document Has Been Signed on 09/28/2022 11:34 AM - 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:VIERA RESIDENTIAL CARE HOMEFACILITY NUMBER:
079200377
ADMINISTRATOR:TASHA WOODSFACILITY TYPE:
735
ADDRESS:2129 VIERA AVENUETELEPHONE:
(925) 756-1686
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 4DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Tasha Woods, AdministratorTIME COMPLETED:
11:45 AM
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On 9/28/2022 at 10:05AM, Licensing Program Analysts (LPAs) L. Hall and L. Alexander arrived unannounced to conduct an Infection Control Inspection. Administrator Tasha Woods, arrived at 10:28AM. and LPA explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs were posted. LPA toured facility including but not limited to common areas, bathrooms stations, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 102.9 degrees Fahrenheit. Fire extinguisher last serviced on 3/16/2021. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors log and temperature log for both clients and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed food and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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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: VIERA RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200377
VISIT DATE: 09/28/2022
NARRATIVE
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Continued from LIC809.

The following deficiency was observed:

-At 10:54AM, LPA observed fence in back yard had planks missing in two (2) places.

LPA request the following documents to be submitted to CCLD by 10/5/2022.

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610D Emergency Disaster Plan
Administrator certificate

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted. A copy of this report provided and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/28/2022 11:34 AM - It Cannot Be Edited


Created By: Laura Hall On 09/28/2022 at 11:15 AM
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: VIERA RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 in having fence in back yard repaired. Fence is missing planks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Administrator agreed to replace missing planks on fence and submit a photo copy to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022


LIC809 (FAS) - (06/04)
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