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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200378
Report Date: 02/15/2023
Date Signed: 02/15/2023 04:47:22 PM


Document Has Been Signed on 02/15/2023 04:47 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 IIFACILITY NUMBER:
079200378
ADMINISTRATOR:TASHA WOODSFACILITY TYPE:
735
ADDRESS:4680 PINOT COURTTELEPHONE:
(925) 679-1962
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 4DATE:
02/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Tasha Woods, Administrator TIME COMPLETED:
05:10 PM
NARRATIVE
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On 02/15/2023 at 3:35 PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a case management visit due to incident report received on 02/13/2023, C1 sustained left foot fracture. LPA met with Administrator, Tasha Woods. LPA explained the purpose of the visit.

Based on records review and interview, on the morning of 2/11/2023, C1 went out to play basketball, at around 9:00PM C1 reported to staff that he twisted his ankle while playing basketball, staff place an ice pack on the affected foot of C1. On 2/11/2023 at around 11:00PM, staff iced C1’s left ankle and wrapped it with bandage. On 2/12/2023 at around 1:00AM, C1 verbalized of pain on the affected side, records review revealed that staff placed a packed of ice on C1’s ankle although staff already observed that C1’s ankle was swollen. On 02/13/2023 at around 9:00AM, C1 asked Administrator to take him to Emergency room for his ankle. On the same day C1 was diagnosed with close fracture of the malleolus.

Based on LPA’s observation during the visit, C1 have a cast on his left foot. Based on interview with C1, he is okay with a little bit of pain and staff are assisting him about his case.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

A $500.00 immediate civil penalty was assessed during the visit.

Exit interview conducted with Tasha Woods. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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 2


Document Has Been Signed on 02/15/2023 04:47 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: VIERA RESIDENTIAL CARE HOME II
FACILITY NUMBER: 079200378

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2023
Section Cited

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 Health-Related Services
(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.

This requirement is not met as evidence by:
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Administrator agreed to conduct an in-service all staff regarding the regulation cited. A copy of proof of training with staff names, signature and training topic need to be submitted to CCL by POC date.
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Based on interview and records review , the licensee did not comply with the section cited above in Administrator failed to take C1 to the emergency room or doctor not until two days after C1 twisted his ankle which poses an immediate health, safety or personal rights risk to persons in care.
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Civil penalty of $500 assessed during the visit.
Type A
02/16/2023
Section Cited

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Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
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Administrator agreed to conduct an in-service all staff regarding the regulation cited. A copy of proof of training with staff names, signature and training topic need to be submitted to CCL by POC date.
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-Based on interviews and records review, the licensee did not comply with the above Regulation when C1 reported to staff that he twisted his ankle, staff failed to take him to emergency room or to doctor right away. This posed an immediate safety risk to person in care.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2