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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200569
Report Date: 08/31/2022
Date Signed: 08/31/2022 03:38:22 PM


Document Has Been Signed on 08/31/2022 03:38 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:PLEASANT HILL VILLA HOME CAREFACILITY NUMBER:
079200569
ADMINISTRATOR:M. ELAZEGUI & G. MAGATFACILITY TYPE:
740
ADDRESS:3021 PUTNAM BLVDTELEPHONE:
(408) 933-8663
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 3DATE:
08/31/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Gliceria Magat, Licensee
Christina Elazegui, Administrator		TIME COMPLETED:
03:52 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 8/31/2022 at 1:30PM, Licensing Program Analysts (LPAs) G. Luk and J. Sampair arrived unannounced to conduct a health and safety check as a result of a priority 1 complaint. LPAs met with Licensee, Gliceria Magat. Administrator, Christina Elazegui arrived an hour later.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, garage and outdoor area. Facility temperature was maintained at 76.6 degrees F. Hot water temperature was measured at 108 degrees F in kitchen sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in the cabinet. Smoke and Carbon monoxide detectors observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 6/29/2022. There are no accessible bodies of water observed.

At 1:00PM, LPAs observed a bottle of furniture polish stored next to can goods in the garage storage. Licensee removed the furniture polish during inspection.

At 1:03PM, LPAs observed unlocked garage door which had cleaning supplies and laundry detergent accessible. Cabinet under the sink was unlocked with cleaning supplies. LPAs also observed unlocked scissors in the drawer. Staff locked up disinfectant, cleaning supplies, and knives during inspection.

At 1:05PM, LPAs observed air vent on the ceiling by the garage door and hallway bathroom appears to be loose and may be falling down. Ceiling vent in the hallway by the front door has cobwebs. Room #3 toilet seat is missing and floor of shower was dirty. Gate latch in the deck area is in disrepair and until to self-close.

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.
Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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


Document Has Been Signed on 08/31/2022 03:38 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: PLEASANT HILL VILLA HOME CARE
FACILITY NUMBER: 079200569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2022
Section Cited

1
2
3
4
5
6
7
Storage Space. Disinfectants, cleaning solutions...and other items which could pose a danger...shall be stored where inaccessible to clients. This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by having unlocked cleaning supplies and scissors in the kitchen and garage which poses an immediate health and safety risk to the persons in care.
8
9
10
11
12
13
14
Civil penalty of $250 is being assessed for repeat violation.
Type B
09/01/2022
Section Cited

1
2
3
4
5
6
7
General Food Service Requirements. The following...shall apply: Soaps, detergents, cleaning compounds...shall be stored in areas separate from food supplies. This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by having furniture polish stored next to food supplies which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14
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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/31/2022 03:38 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: PLEASANT HILL VILLA HOME CARE
FACILITY NUMBER: 079200569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2022
Section Cited

1
2
3
4
5
6
7
Maintenance and Operation.
The facility shall be clean, safe, sanitary and in good repair at all times...
This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by having vent and gate latch in disrepair, vents and shower not clean, and missing toilet seat which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3