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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200616
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:17:10 PM

Document Has Been Signed on 03/07/2023 04:17 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:LUCCHESI GROUP ADULT RESIDENTIAL CAREFACILITY NUMBER:
079200616
ADMINISTRATOR:VALADEZ, ARMANDOFACILITY TYPE:
735
ADDRESS:4739 LUCCHESI COURTTELEPHONE:
(925) 457-0913
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 4DATE:
03/07/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Administrator RAFAEL RUBIO MARTINTIME COMPLETED:
04:30 PM
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On 03/07/2023, Licensing Program Analysts (LPAs) J. Sampair arrived unannounced to conduct a health and safety check as a result of a Priority 2 complaint. LPA met with Administrator RAFAEL RUBIO MARTIN.

LPA toured facility including but not limited to the bedrooms, bathrooms, common areas, kitchen, and outdoor areas. An adequate supply of Personal Protective Equipment (PPE) was on hand. The facility temperature was maintained at 68.5 degrees F. Facility cited for the unsafe hot water temperature that was measured at 124 degrees F in the kitchen sink.

There was a sufficient supply of food, with 7-days of non-perishable and 2-days of perishable food on hand. Resident medications were kept in a locked cabinet. Smoke and Carbon monoxide detectors tested and were functional. First-aid kit was complete. Fire extinguishers were observed to be full and last serviced on 06/17/2022. There are no accessible bodies of water observed..

One (1) Type-A citation was issued (refer to LIC 809-D).

Exit interview conducted and a copy of this report was provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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 03/07/2023 04:17 PM - It Cannot Be Edited


Created By: James Sampair On 03/07/2023 at 03:45 PM
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: LUCCHESI GROUP ADULT RESIDENTIAL CARE
FACILITY NUMBER: 079200616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2023
Section Cited
CCR
80088(e)(1)

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FIXTURES, FURNITURE, EQUIPMENT AND SUPPLIES (e) Faucets used by clients ... shall deliver hot water. (1) Hot water temperature controls shall ... attain a hot water temperature of not less than 105 degrees F ... and not more than 120 degrees F

This requirement is not met as evidenced by:
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cleared during inspection.
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Based on observation, the licensee did not comply with the section cited above with the hot water temperature measured at 124 degrees F in the kitchen sink, which poses an immediate health, safety or personal rights risk to 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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
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