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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200794
Report Date: 02/15/2023
Date Signed: 02/15/2023 10:49:00 AM


Document Has Been Signed on 02/15/2023 10:49 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:TICE VALLEY RESIDENTIAL CAREFACILITY NUMBER:
079200794
ADMINISTRATOR:SANTIAGO, RACHELLE HFACILITY TYPE:
740
ADDRESS:2206 TICE VALLEY BLVDTELEPHONE:
(925) 705-7841
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 5DATE:
02/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:MARK GUTIERREZTIME COMPLETED:
10:55 AM
NARRATIVE
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During a health check visit on 02/15/2023, Licensing Program Analyst (LPA) James Sampair observed a deficiency concerning care for persons with dementia. During the LPA's inspection of the exterior of the building, it was observed that one of the 3 gates were not self-closing, for details refer to LIC 809D.

One citation was issued during inspection.

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: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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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Document Has Been Signed on 02/15/2023 10:49 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: TICE VALLEY RESIDENTIAL CARE
FACILITY NUMBER: 079200794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2023
Section Cited

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87705 Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
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On or before due date, Licensee shall add self-closing mechanism to the gate without one.
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Based on observation, the licensee did not comply with the section cited above in 1 out of 3 gates that was not self-closing, which poses a potential health, safety or personal rights 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: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
LIC809 (FAS) - (06/04)
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