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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200883
Report Date: 04/03/2024
Date Signed: 04/03/2024 02:16:46 PM

Document Has Been Signed on 04/03/2024 02:16 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LA CALLE HAVENFACILITY NUMBER:
079200883
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		LIPARDO, MELISSAFACILITY TYPE:
735
ADDRESS:1775 LA CALLETELEPHONE:
(925) 822-3610
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 6DATE:
04/03/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Bernadette Aguila, AdministratorTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 04/03/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a Health & Safety inspection as a result of another Case Management. LPA met with Administrator, Bernadette Aguila and explained the purpose of the visit. Bernadette phoned the Licensee, Melissa Lipardo to inform the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 114.7 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility purchases food supplies on a weekly basis. Resident's medications were kept locked in cabinet. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 11/06/2023.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 12:35 PM, LPA observed knives unlocked in kitchen drawer and 2 bottles of cleaning disinfection sprays and cleaners under the kitchen sink
At 12:36 PM, LPA observed Clorox Multi Disinfection Spray and Lysol Spray located under the shared bathroom sink

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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 04/03/2024 02:16 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 04/03/2024 at 01:13 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: LA CALLE HAVEN
FACILITY NUMBER: 079200883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2024
Section Cited
CCR
80087(g)(1)

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80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
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Administrator will self-certify that they have read and understand the regulation and submit self-certification to CCLD by POC due date.
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Based on observation, the licensee did not comply with the section cited above by not having knives/sharps and cleaning disinfective sprays in accessible to clients which poses a potential health and safety risk to persons in care.
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Also Administrator agree to get a new lock placed under kitchen sink cabinet and will send a photo to CCLD by POC due date.

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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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
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