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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200772
Report Date: 03/04/2022
Date Signed: 03/04/2022 04:33:17 PM

Document Has Been Signed on 03/04/2022 04:33 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) 705-8635
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
03/04/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Monique Woods, House ManagerTIME COMPLETED:
04:45 PM
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On 3/4/2022 at 2:00PM, Licensing Program Analysts (LPAs) G. Luk and L. Fici conducted an unannounced Health & Safety inspection as a result of a priority 2 complaint. LPAs met with House Manager, Monique Woods and informed her reason for visit.

LPAs toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, garage, and outdoor area. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Client's medications were kept locked in the living room cabinet. Smoke and carbon monoxide detectors observed. First-aid kit was complete. Fire extinguisher was observed to be full. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

At 2:30PM, LPAs measured hot water at 128 degrees F in the hallway bathroom sink.

At 2:45PM, LPAs observed unlocked cleaning supplies under the kitchen sink and unlocked detergent the laundry area. Staff locked up the cleaning supplies and detergent during visit.

At 2:50PM, LPAs observed window screens in room 4 and in master bathroom was broken. Blinds in room 4 was also broken. LPAs observed backyard side fence was missing a few panels.

At 3:00PM, LPAs observed S1 was not fingerprint cleared and have been working at the facility for a week.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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 3
Document Has Been Signed on 03/04/2022 04:33 PM - It Cannot Be Edited


Created By: Grace Luk On 03/04/2022 at 03:13 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2022
Section Cited
CCR
80019(e)(1)

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Criminal Record Clearance.
Obtain a California clearance or a criminal record exemption as required by the Department or...
This requirement is not met as evidence by:
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Uncleared staff left the facility during inspection and will not return until fingerprint clearance is completed. House manager agreed to follow up with CPMB regarding S1's fingerprint clearance and submit documentation to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by having a staff work at the facility without fingerprint clearance which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $500 is being assess.
Type A
03/05/2022
Section Cited
CCR80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies. Hot water temperature controls shall be maintained...not less than 105 degrees F and not more than 120 degrees F. This requirement is not met as evidence by:
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House manager turned down the hot water, but hot water was at 135 degrees F. House manager will send video of hot water temperature by POC date.
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Based on observation, licensee did not comply with the section cited above by having hot water at 128 degree F which poses an immediate health and safety risk to the persons 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/04/2022 04:33 PM - It Cannot Be Edited


Created By: Grace Luk On 03/04/2022 at 03:41 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2022
Section Cited
CCR
80087(g)

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Buildings and Grounds. Disinfectants, cleaning solutions, ...and other items that could pose a danger...shall be stored where inaccessible to clients. This requirement is not met as evidence by:
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Staff locked up the cleaning supplies and detergents during inspection.

Deficiency cleared during inspection
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Based on observation, licensee did not comply with the section cited above by having unlocked cleaning supplies and detergents which poses an immediate health and safety risk to the person in care.
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Type B
03/14/2022
Section Cited
CCR80087(a)

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Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times ...
This requirement is not met as evidence by:
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House manager has agreed to repair the window screens in room 4 and master bathroom, blinds in room 4, and missing fence panels by POC date. House manager will submit photos of repair by POC date.
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Based on observation, licensee did not comply with the section cited above by having broken window screens and missing fence panel which poses a potential health and safety risk to the person 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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