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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200630
Report Date: 02/01/2023
Date Signed: 02/01/2023 02:18:17 PM


Document Has Been Signed on 02/01/2023 02:18 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:BYRON PARKFACILITY NUMBER:
079200630
ADMINISTRATOR:JENNIFER MURRAY PASTORAFACILITY TYPE:
740
ADDRESS:1700 TICE VALLEY BLVDTELEPHONE:
(925) 937-1700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:151CENSUS: 89DATE:
02/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica GurnackTIME COMPLETED:
11:30 AM
NARRATIVE
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On 02/01/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Case Management visit concerning an Unusual Incident Report (UIR) about staff S1 transferring and dispensing resident R2's medication to resident R1 on 01/21/2023. LPA met with Assisted Living Director (ALD) Jessica Gurnack, LVN and Assistant Executive Director (AED) Cayia Henry.

During the meeting, the LPA, AED, and ALD discussed the outcomes of their internal investigation, which concluded in dismissing staff member S1. They also discussed the follow up work they will be doing to retrain staff on 02/02/2023 on the foundations of medication dispensing.

One Type B citation was issued. Refer to LIC809-D.

Exit interview conducted and 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: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
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 02/01/2023 02:18 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: BYRON PARK
FACILITY NUMBER: 079200630

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/08/2023
Section Cited

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(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
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Complete internal incident investigation. Medication training and meeting scheduled. Medication Audit. Completed during inspection.
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Staff S1 transferring medication from the bottle of resident R2 to the bottle of resident R1.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
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