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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200569
Report Date: 10/04/2021
Date Signed: 10/04/2021 06:19:57 PM

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:PLEASANT HILL VILLA HOME CAREFACILITY NUMBER:
079200569
ADMINISTRATOR:MAGAT, GLICERIA MFACILITY TYPE:
740
ADDRESS:3021 PUTNAM BLVDTELEPHONE:
(408) 933-8663
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 4DATE:
10/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Gliceria Magat and Maria Christina ElazeguiTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrators Gliceria Magat and Maria Christina Elazegui. LPA observed all staff wearing face masks during the visit. Maria Christina Elazegui is the designated Infection control leader. LPA discussed the mitigation plan with them, as well as their current COVID-19 infection control practices. They have conducted staff training on infection prevention, symptoms, transmission, as well as the proper donning and doffing of PPE. All of the staff and residents were fully vaccinated.

LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with a digital visitor's log, hand sanitizer, face masks, and a no-touch temperature probe. Routine symptom screening (+/-) temperature and symptom check is done at entry for all staff, residents, and visitors. LPA observed COVID-19 signs posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents.

Pathways were observed to be free of obstruction and fire hazards. There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper and PPE supplies were observed. Facility room temperature was maintained at a comfortable temperature and the water temperature was in the acceptable range. A certified administrator is on site at all times to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged and last inspected in June 2021 and the Smoke and Carbon monoxide detectors were fully operational.

LPA observed two citations that have been written up on the LIC809-D for 1 Type A and 1 Type B deficiencies that were both corrected before the LPA left the facility.

Exit interview conducted and a copy of this report and copies of the Appeal Rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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: PLEASANT HILL VILLA HOME CARE
FACILITY NUMBER: 079200569
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2021

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
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Based on observation, the licensee did not comply with the section cited above in one (1) of the drawers in the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2021
Plan of Correction
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Fix the lock on the kitchen drawer and send proof of it's repair to LPA by End of Business on 10/05/21.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2021
LIC809 (FAS) - (06/04)
Page: 2 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: PLEASANT HILL VILLA HOME CARE
FACILITY NUMBER: 079200569
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

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 the refrigerator in the garage that had food on the bottom shelf, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2021
Plan of Correction
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Clean the spilled food off the floor of the regrigerator by End of Business 10/11/21.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3