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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200772
Report Date: 06/02/2023
Date Signed: 06/02/2023 06:03:44 PM

Document Has Been Signed on 06/02/2023 06:03 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:REVITALIZE CARE HOME LLCFACILITY NUMBER:
079200772
ADMINISTRATOR:DACE, GENEVIEVEFACILITY TYPE:
735
ADDRESS:1913 CARDIFF DRTELEPHONE:
(925) 267-9822
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Rachelle Wormely, House ManagerTIME COMPLETED:
06:15 PM
NARRATIVE
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On 6/2/2023 at 03:05PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Rachelle Wormely, House Manager, and explained the purpose of the visit. Administrator, Genevieve Dace, arrived at 4:00PM. The administrator currently holds a certificate (#6047392735) that expires on 6/19/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and two (2 ) bathrooms, which one (1) bedroom is being used as an office. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 79 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 117.9 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Bathrooms were equipped with non skid mats. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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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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: REVITALIZE CARE HOME LLC
FACILITY NUMBER: 079200772
VISIT DATE: 06/02/2023
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last purchased on 10/19/2022. Fire drill last conducted 5/05/2023. First aid kit was observed to be complete.

Three (3) staff records were reviewed, and all staff have first aid and CPR. Administrator file was not present at the facility. All five (5) clients records were reviewed and four (4) were missing the physician's report. LPA also reviewed P&I.

The following forms to be updated and submitted to CCLD by 6/9/2023:
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC 610D Emergency disaster plan
  • Liability insurance.
  • LIC500 (Personnel Record)
  • Client Roster

The following deficiencies were observed:

-At 3:25pm, LPA observed four (4) client files did not contain the physician's report (LIC602).
-At 3:53pm, LPA observed the Administrator did not have a file present at facility.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2023 06:03 PM - It Cannot Be Edited


Created By: Laura Hall On 06/02/2023 at 05:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REVITALIZE CARE HOME LLC
FACILITY NUMBER: 079200772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having missing medical assessments for 4 clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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Administrator agreed to obtain medical assessments (physician's reports) for 4 of the clients and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in the Administrator file present at the facility for review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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Administrator agreed to review regulation 80066, and submit self-certification that facility will abide by facility going forward to CCLD by POC 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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


LIC809 (FAS) - (06/04)
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