<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200537
Report Date: 12/22/2022
Date Signed: 12/22/2022 12:11:25 PM


Document Has Been Signed on 12/22/2022 12:11 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:VITAFACILITY NUMBER:
079200537
ADMINISTRATOR:BUYNEVICH, TATYANAFACILITY TYPE:
740
ADDRESS:4012 BLACKSMITH CIRTELEPHONE:
(925) 516-6470
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 6DATE:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Fatima Mendez, staff on duty TIME COMPLETED:
12:30 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 12/22/2022 at 10:00AM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and met with S2, LPA called Administrator (S1) and explained the purpose of the visit. Administrator is not available during the visit, S1 stated that S2 will receive copy of the report. LPA observed 5 residents during the visit and one resident was at the hospital. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 73 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.

LPA observed the following:

· Unlocked disinfectants, medications and two pair of scissors accessible to residents in care
· Side gate was observed to be locked

...Continue to LIC809C...

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
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 3


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: VITA
FACILITY NUMBER: 079200537
VISIT DATE: 12/22/2022
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
26
27
28
29
30
31
32
Technical assistance provided to Administrator and facility staff on the following topics:

· Additional covid19 posters needed at the facility’s common area
· Facility needs trash bin with lid on all bathrooms
· Paper towel with paper towel holder needed for all wash area
· Facility needs a sign-in policy with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).
· Facility needs to implement routine symptom screening (+/- temperature and symptom check) to be initiated at entry for all staff, residents, and visitors.
· Facility needs to document daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents. LPA conducted records review and only observed couple of days monitoring for residents and staff. LPA provided technical assistance and reminded staff and S1 that daily temperature and covid19 symptoms checks needs to be documented.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with S2.



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

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/22/2022 12:11 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: VITA
FACILITY NUMBER: 079200537

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in facility staff failed to lock disinfectants, medications and two pair of scissors which was accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2022
Plan of Correction
1
2
3
4
Cleared during the visit. S2 locked disinfectants , medications and scissors.
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.



This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in staff failed to unlocked side gate=which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2022
Plan of Correction
1
2
3
4
Staff unlock side gate
Corrected during the visit.
Administrator will train all staff regarding the citation, proof of training needs to be submitted on CCL office on 12/27/2022
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: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3