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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200765
Report Date: 04/28/2023
Date Signed: 04/28/2023 04:59:16 PM


Document Has Been Signed on 04/28/2023 04:59 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:PLEASANT HILL OASISFACILITY NUMBER:
079200765
ADMINISTRATOR:ELEGADO, LIZAFACILITY TYPE:
740
ADDRESS:40 BOYD RDTELEPHONE:
(925) 937-5348
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:44CENSUS: 44DATE:
04/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Liza Elegado, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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On 04/28/2023 at 11:55 AM, Licensing Program Analysts (LPAs), L. Alexander and C. Fowler arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint. LPAs met with Executive Director, Liza Elegado and explained the reason for the visit.

LPAs observed clients sitting in common area, backyard and activity room preparing for a birthday party.

During the health and safety check, LPAs toured the building with Liza Elegado including but not limited to kitchen, common areas, bathrooms, bedrooms and outdoor area.

LPAs observed the following deficiencies during the tour:

At 11:57 AM LPAs observed Microban Disinfected Spray, disinfectant spray bottle under sink in shower room
At 12:00 PM LPAs observed Ridgid Blower located in backyard next to residence smoking area
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PLEASANT HILL OASIS
FACILITY NUMBER: 079200765
VISIT DATE: 04/28/2023
NARRATIVE
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Continued from LIC 809

At 12:01 PM LPAs observed Amana washing machine, dolly located backyard
At 12:04 PM LPAs observed dresser, white file cabinet, chairs located side yard
At 12:06 PM LPAs observed luggage, TV, DVDs, boxes, vending machine, wood coffee table, located back yard
At 12:07 PM LPAs observed Masonry Mortar, toilet camode, wheel barrel located side yard
At 12:08 PM LPAs observed weathered doors to storage rooms missing with door knobs located side yard
At 12:09 PM LPAs observed unlocked door to Electrical Room located side yard

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/28/2023 04:59 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: PLEASANT HILL OASIS
FACILITY NUMBER: 079200765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2023
Section Cited

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(f) The following shall be stored inaccessible to...
(2)... toxic substances such ...cleaning supplies and disinfectants. This requirement was not met by evidenced by:
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Administrator had maintenance lock the chemicals. Deficiency cleared during visit
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Based on LPAs observation the Licensee did not comply with the section cited above by having: Microban Spray,disinfectant spray bottle under sink in shower room accessible to residents in care.
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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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/28/2023 04:59 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: PLEASANT HILL OASIS
FACILITY NUMBER: 079200765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited

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(d) ...safety provisions shall apply...(2) The premises...in a state of good repair...This requirement was not met as evidenced by:
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Administrator agreed to purchase locks for sheds, replace wheathered doors. door knobs and locks, remove items stored in back and side yards.
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Based on observation the Licensee did not comply with section cited above by not having the facility in a state of good repair...
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Administrator will send photo copies of all repairs to CCLD no later than POC due date.
Type B
05/05/2023
Section Cited

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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Administrator agreed to have R1 vacate the room and submit a LIC 200 along with an updated facility sketch to request for a new fire clearance.
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Based on observation and records review Administrator failed to have storgae room cleared as a living space prior to R1 residing there which poses a potential health and safety risk to residents in care.
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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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4