079200377-10-5-2023-15-AS-LHAL-CWBR64-20231005124408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200377
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:44:19 PM

Document Has Been Signed on 10/05/2023 12:44 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:	VIERA RESIDENTIAL CARE HOME		FACILITY NUMBER:	079200377
ADMINISTRATOR:	TASHA WOODS		FACILITY TYPE:	735
ADDRESS:	2129 VIERA AVENUE		TELEPHONE:	(925) 756-1686
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY: 6		CENSUS: 5	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Dane McCoy, Licensee		TIME COMPLETED:	12:50 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 10/5/2023 at 10:00am, Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced annual 1-year required inspection. LPAs met with Dane McCoy, Licensee, whom arrived at 10:35 and explained the purpose of the visit. The administrator currently holds a certificate (#6032517735) that expires on 10/14/2024. The facility’s fire clearance was approved for six (6) ambulatory clients. No clients present during inspection. 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. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 73 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 106.7 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. Fire extinguisher was last services on 3/16/2022. Fire drill last conducted 2/8/2023. First aid kit was observed to be complete. Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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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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: 10/05/2023

NARRATIVE

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Continued from LIC809.

Four (4) staff records were reviewed, One (1) of four (4) staff did not have current first aid certification. All five (5) clients' records were reviewed and all are missing a current appraisal needs and services plan.

LPA observed the following deficiencies:

At 11:15am, LPA observed during record review that all clients did not have a current appraisal needs and services plan.

The following forms to be updated and submitted to CCLD by 10/12/2023:

LIC610D Emergency disaster plan (9 pages)
LIC500 (Personnel Record)
Client Roster
LIC308 (Designation of facility Responsibility)

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: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/05/2023 12:44 PM - It Cannot Be Edited

Created By: Laura Hall On 10/05/2023 at 12:33 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: VIERA RESIDENTIAL CARE HOME	FACILITY NUMBER: 079200377
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80068.2(a)

80068.2 Needs and Services Plan (a) The licensee shall complete a Needs and Services Plan for each client as required in Sections 81068.2, 82068.2, 82568.2, or 85068.2. 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 an updated appraisal needs and services plan for each client which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Administrator will complete an appraisal needs and services plan for each client and submit a self-certification that they have been completed 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: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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