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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200877
Report Date: 11/30/2021
Date Signed: 12/01/2021 11:36:41 AM

Document Has Been Signed on 12/01/2021 11:36 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:NATIONAL PSYCHIATRIC CARE AND REHAB SERVICES INCFACILITY NUMBER:
079200877
ADMINISTRATOR:SHAMLY JOHALFACILITY TYPE:
772
ADDRESS:2181 TICE VALLEY BLVDTELEPHONE:
(925) 478-3795
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 12CENSUS: 5DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Staff Kingsley Nwala and Candyce Pirtle-SmallsTIME COMPLETED:
05:18 PM
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. Facility has a completed COVID-19 mitigation plan (LIC 808) in place. The facility has a single entrance with signs concerning mask wearing and other infection control advisories to protect from Covid-19.

Upon arrival, LPA explained the purpose of the visit to Staff Member Kingsley Nwala, who then accompanied LPA during the inspection inside and outside of the facility. LPA observed that temperature, Covid-19 symptom screening, proof of Covid-19 vaccination, hand sanitizer, and face masks upon entry for all staff, residents, and visitors. LPA observed COVID-19 signs posted in common areas and restrooms to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. LPA observed all staff wearing face masks during visit.

Program Manager Candyce Pirtle-Smalls arrived after LPA's tour of the facility and explained that Director Shamly Johal was self-quarantining after close exposure to someone who has Covid-19. Regular training has been conducted on infection prevention, symptoms, transmission and proper donning and doffing of PPE. All staff and residents are fully vaccinated.

There were sufficient food and water supplies and PPE supplies. The facility room temperature was maintained at a comfortable level and the hot water temperature was within the safe 105 to 120 degree range. A certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operation.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report was provided to the administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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