079200620-10-28-2021-15-AS-JSAR-C893H8-20211028181532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200620
Report Date: 10/28/2021
Date Signed: 10/28/2021 06:15:55 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:	ROCK OAK VILLA		FACILITY NUMBER:	079200620
ADMINISTRATOR:	COPE, JENETTE		FACILITY TYPE:	740
ADDRESS:	594 ROCK OAK ROAD		TELEPHONE:	(415) 533-7504
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 4	DATE:	10/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anna Manglicmot		TIME COMPLETED:	06:30 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	Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection of the facility inside and outside. Upon entry into the facility, LPA observed that 0 of 2 staff members were wearing any facial covering, nor did they ask him to verify his vaccination status. There was a screening station located near the front entrance. COVID-19 signs were posted in common areas to promote hand washing and physical distancing. Staff document temperature and health status for staff and residents on a daily basis. Within 30 minutes, the Administrator (ADM) and designated Infection control leader Anna Manglicmot arrived. The LPA explained the purpose of the visit and the ADM accompanied him during the tour of the facility. The ADM reported that all staff and residents were fully vaccinated. The LPA observed that the temperature within the facility was maintained at a comfortable temperature, but the hot water was over the maximum of 120 degrees Fahrenheit. There were sufficient food and water supplies. The Smoke and Carbon monoxide detectors were fully operational. and the fire extinguishers were fully charged and last inspected in August 2021. Though staff had been trained in the past on infection prevention, symptoms, transmission, and proper donning and doffing of PPE, no copy of the COVID-19 mitigation plan was at the facility, so the LPA reviewed several infection control topics with the ADM, including: verifying vaccination status for visitors, FIT testing, and the proper amount of PPE necessary during an outbreak. In addition to the deficiencies noted above, a total of 4 Type A and 3 Type B, and 2 Technical Assistances, the details of which are in the LIC809-D citations: -------------Continued on LIC809-C---------------

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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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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: ROCK OAK VILLA	FACILITY NUMBER: 079200620
	VISIT DATE: 10/28/2021

NARRATIVE

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Infection Control Practices - Technical Assistance: 2 staff not wearing face covering upon LPA entry
Infection Control Practices - Technical Assistance: not a 30 day supply of PPE
Physical Plant/Environmental Safety - Type B: 87303(a) - gate giving access to unlocked storage shed could not close
Physical Plant/Environmental Safety - Type A: 87303(e)(2) - hot water temperature 122 degrees F
Physical Plant/Environmental Safety - Type A: 87309(a) - knives were stored in unlocked drawer in kitchen and cleaners in unlocked cabinets in laundry room
Incidental Medical and Dental - Type A: 87465(h)(2) - medication cabinet unlocked
Disaster Preparedness - Type B: 1569.695(a)(2) - no emergency food and water nor a fully developed plan
Disaster Preparedness - Type B: 1569.695(a)(7)(A) - no emergency generator
Residents with Special Health Needs - Type A: 87606(c) - 1 bedridden resident retained without license to do so

Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC809 (FAS) - (06/04)

Page: 2 of 7

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: ROCK OAK VILLA	FACILITY NUMBER: 079200620
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 when the hot water was 122 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2021
	Plan of Correction
1 2 3 4	Send proof to LPA that hot water temperature reduced to the 105 to 120 degree range.

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 when knives were stored in unlocked drawer in kitchen and cleaners in unlocked cabinets in laundry room, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2021
	Plan of Correction
1 2 3 4	Lock doors and by 11/4/21 send proof to LPA that non-functioning locks have been replaced with fully functioning locks.

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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC809 (FAS) - (06/04)

Page: 3 of 7

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: ROCK OAK VILLA	FACILITY NUMBER: 079200620
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 when medication cabinet unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2021
	Plan of Correction
1 2 3 4	Lock doors and by 11/4/21 send proof to LPA that non-functioning locks have been replaced with fully functioning locks.

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). 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 1 bedridden resident retained without license to do so, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2021
	Plan of Correction
1 2 3 4	Request an exception for resident in writing to LPA. No later than 11/2/21, submit LIC200 to update facility license to include bedridden residents, along with an updated yard sketch (LIC999) that indicates the totality of the site plan including the fence and 2 storage sheds missing from the existing yard sketch.

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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC809 (FAS) - (06/04)

Page: 4 of 7

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: ROCK OAK VILLA	FACILITY NUMBER: 079200620
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 where the gate giving access to unlocked storage shed could not close, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/04/2021
	Plan of Correction
1 2 3 4	Repair the gate so it will close.

Type B

Section Cited

HSC

1569.695(a)(2)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. 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 no emergency food and water nor a fully developed and implemented plan, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/11/2021
	Plan of Correction
1 2 3 4	Develop and implement a full plan, which includes getting all of the emergency food and water and separating it so it does not get used for non-emergency purposes.

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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC809 (FAS) - (06/04)

Page: 5 of 7

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: ROCK OAK VILLA	FACILITY NUMBER: 079200620
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)(7)(A)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (A) Provision of emergency power that could include identification of suppliers of backup generators. If a permanently installed generator is used, the plan shall include its location and a description of how it will be used. If a portable generator is used, the manufacturer’s operating instructions shall be followed. 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 by not purchasing and setting up in place an emergency generator, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/11/2021
	Plan of Correction
1 2 3 4	Purchase an emergency generator and fuel to power it for a minimum of 72 hours.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC809 (FAS) - (06/04)

Page: 6 of 7