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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200569
Report Date: 09/17/2021
Date Signed: 09/17/2021 11:57:30 AM

Document Has Been Signed on 09/17/2021 11:57 AM - 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:MAGAT, GLICERIA MFACILITY TYPE:
740
ADDRESS:3021 PUTNAM BLVDTELEPHONE:
(408) 933-8663
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 5DATE:
09/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Gliceria Magat, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On 09/17/2021 at 11:15AM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit. LPA met with Gliceria Magat, Administrator and explained the purpose of the visit

When LPA L. Hall arrived to deliver complaint findings (15-AS-20201028095918) on 09/17/2021, LPA observed four (4) monitors on dining room table monitoring residents in their bedrooms. LPA inquired with staff about monitors and was advised used for fall risk residents. Record review indicated one (1) of five (5) residents as fall risk.

The deficiencies was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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Document Has Been Signed on 09/17/2021 11:57 AM - It Cannot Be Edited


Created By: Laura Hall On 09/17/2021 at 11:21 AM
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: PLEASANT HILL VILLA HOME CARE
FACILITY NUMBER: 079200569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall have all of the following personal rights:(3)To be free from... ...other actions..., such as... or interfering with daily living functions... This requiremnent was not met as evidence by:
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Administrator agreed to remove monitors. Monitors were removed during visit. Deifciency cleared during visit.
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Based on LPA's observation Licensee did not comply with the section cited above, which poses a potentitial health and safety risk for persons 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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021


LIC809 (FAS) - (06/04)
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