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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200620
Report Date: 09/20/2022
Date Signed: 09/20/2022 01:34:45 PM


Document Has Been Signed on 09/20/2022 01:34 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:ROCK OAK VILLAFACILITY NUMBER:
079200620
ADMINISTRATOR:COPE, JENETTEFACILITY TYPE:
740
ADDRESS:594 ROCK OAK ROADTELEPHONE:
(415) 533-7504
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anna ManglicmotTIME COMPLETED:
02:00 PM
NARRATIVE
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On 9/20/22 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit to staff and conducted the initial inspection of the facility. Administrator Anna Manglicmot arrived later and together they toured the facility and discussed the deficiencies identified during LPA's initial inspection.

Facility has an infection control plan in place that they are following. The designated infection control leader is Jeanette Cope. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. Facility had signs posted to promote hand washing and mask wearing.

The fire extinguisher has been serviced within the past 12 months, and the carbon monoxide and smoke detectors were fully functional. The temperature inside of the facility was 70.7 and the hot water was 110 degrees, which were in the safe temperature range. An administrator is on site at least the required 20 hour minimum each week to oversee business operations.

Facility cited for 2 Type A deficiencies due to unlocked storage cabinets of medications and cleaners in the laundry room (refer to LIC 809-D).

Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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 09/20/2022 01:34 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: ROCK OAK VILLA
FACILITY NUMBER: 079200620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

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 the garage and laundry room where poisonous cleaners were stored, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Corrected during inspection.
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
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4
Based on observation, the licensee did not comply with the section cited above in the medication cabinets that were not locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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4
Corrected during inspection.

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: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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