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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200757
Report Date: 07/06/2022
Date Signed: 07/07/2022 08:54:31 AM


Document Has Been Signed on 07/07/2022 08:54 AM - 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:WALNUT CREEK CARE HOMEFACILITY NUMBER:
079200757
ADMINISTRATOR:SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:2562 VENADO CAMINOTELEPHONE:
(510) 825-2383
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Asha JainTIME COMPLETED:
06:00 PM
NARRATIVE
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On 07/06/22, Licensing Program Analyst (LPA) James Sampair conducted an unannounced pre-licensing inspection and met with Applicant, Asha Jain. LPA explained purpose of the visit.

LPA toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and backyard. Resident's rooms were equipped with the proper furniture, but inadequate lighting. Resident's rooms had proper bedding and linens. Bathrooms were equipped with grab bars and nonskid mats. Living room is equipped with the proper furniture for the residents. All toxins and sharp objects were locked. Passageways and hallways were free of obstruction. Fire extinguisher is fully charged. Smoke and Carbon Monoxide detectors were operational. Medication cabinet was locked.

Hot water temperature was acceptable at 111 degrees F, the room temperature was 73.6 degrees F, and the freezer temperature was acceptable at 0 degrees F. There were sufficient 2 day perishable and 1 week non-perishable food supplies observed in the refrigerator, freezer, and additional food supplies were observed in storage in the garage. Complaint poster, personal rights, Ombudsman and rights to council posters were observed displayed near the dining area.

There were 2 Type-B deficiencies cited concerning the Physical Plant and Food Service as detailed in the LIC 809-D.

Exit interview conducted 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: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/07/2022 08:54 AM - 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: WALNUT CREEK CARE HOME
FACILITY NUMBER: 079200757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022

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
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Based on observation, 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: 07/13/2022
Plan of Correction
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Licensee shall have these repairs completed: (1) sliding glass door sliding open easily (2) hole in exterior of facility closed (3) repair gate on side of facility and send proof with pictures to LPA, and (4) installation of an audible alarm on exits into garage and outside of home and send proof to LPA by due date.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2022
Plan of Correction
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Licensee shall deep clean kitchen and send proof of cleaning to LPA by due date.

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: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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