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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200782
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:55:52 PM


Document Has Been Signed on 02/27/2024 04:55 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:PVS ASSISTED LIVINGFACILITY NUMBER:
079200782
ADMINISTRATOR:SCATTOLIN, PAULFACILITY TYPE:
735
ADDRESS:150 S. 39TH STREETTELEPHONE:
(925) 705-3020
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:4CENSUS: 4DATE:
02/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Paul Scattolin, AdministratorTIME COMPLETED:
05:10 PM
NARRATIVE
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On 2/27/2024 at 4:10pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management regarding an incident with clients. LPA met with Paul Scattolin, Administrator, and explained the purpose of the visit.

LPA observed during pre-licensing (change of ownership) inspection facility is using studio in back yard for C1 to reside. Studio doesn't match facility sketch submitted for clients' use with fire clearance.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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 02/27/2024 04:55 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: PVS ASSISTED LIVING
FACILITY NUMBER: 079200782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2024
Section Cited
CCR
85087(a)(3)

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85087 (a) ... bedrooms must meet... the following requirements: (3) No room commonly used for other purposes shall be used as a bedroom for any person.(A)... or basements, storage areas, and sheds, or similar detached buildings.
This requirement was not as evidence by:
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Administrator agreed to implement a plan for client to sleep inside the facility and submit plan to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having a client sleep in an unattached building, which poses a potential health and safety risk to 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2