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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200620
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:36:51 PM


Document Has Been Signed on 10/10/2023 02:36 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ROCK OAK VILLAFACILITY NUMBER:
079200620
ADMINISTRATOR:ANNA MANGLICMOTFACILITY TYPE:
740
ADDRESS:594 ROCK OAK ROADTELEPHONE:
(925) 891-4044
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Anna ManglicmotTIME COMPLETED:
03:15 PM
NARRATIVE
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On 10/10/2023 at 9:15 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct an annual inspection. Upon arrival, LPA explained the purpose of the visit to Caregivers Norida Malaca and Esperanza David. Administrator (ADM) Anna Manglicmot arrived at approximately 10:15 AM.

During the Inspection, the LPA inspected the facility inside and outside. LPA interviewed 2 staff members and 2 residents, and reviewed the records of 5 staff and 5 residents.

LPA observed that the facility has a sufficient supply of food: 2 days perishable and 7 days nonperishable. A comfortable inside temperature of 70.4 degrees F was maintained. The facility was clean and the staff attentive to residents' needs.

2 Type-B citations issued (for details refer to LIC809-D).

Exit interview conducted with ADM and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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 10/10/2023 02:36 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ROCK OAK VILLA
FACILITY NUMBER: 079200620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in the files of 5 out of 5 employees, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2023
Plan of Correction
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On or before due date, Licensee shall notify LPA that these tasks have been completed: (1) review the document "Details of Title 22 Regulations for Citations 2023.10.10" sent by LPA and (2) provide the required training listed above and (3) document in writing that all required training has been provided for new and existing staff members as it relates to dementia, medications, etc and (4) add copies of all completed required training into employee files (first aid, etc).
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2023
Plan of Correction
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On or before due date, Licensee shall notify LPA that these tasks have been completed: (1) conduct this quarter's emergency/disaster drill for every shift and every employee and (2) create a binder for this and all future drills and (3) schedule reminders for future drills to be conducted.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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