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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201006
Report Date: 11/29/2022
Date Signed: 11/29/2022 05:43:03 PM


Document Has Been Signed on 11/29/2022 05:43 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:VIAMONTE AT WALNUT CREEKFACILITY NUMBER:
079201006
ADMINISTRATOR:MELODY MITCHELL ALLENFACILITY TYPE:
741
ADDRESS:2801 SHADELANDS DRIVETELEPHONE:
(925) 954-2600
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:300CENSUS: 192DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Melody Mitchell AllenTIME COMPLETED:
06:15 PM
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On 11/29/2022, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced infection control annual inspection. Upon entry, LPA explained the reason for the visit. After tour of the facility with staff members, LPA met with Administrator (ADM) Melody Mitchell Allen.

The facility was following COVID-19 guidelines. Inside and outside, the facility was clean, well maintained, and there were no obstructions. There was a sufficient supply of perishable and nonperishable food on hand and the opened food was labelled. The hot water was 108 degrees and the inside temperature was comfortable. A certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operations.

The facility was cited for 1 A-Type deficiency (refer to LIC809-D forms) and 1 civil penalty for a repeat violation.

By 12/07/2022, Licensee will send updated forms to LPA:
· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance

Exit interview conducted, copy of Appeal Rights, 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: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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 11/29/2022 05:43 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: VIAMONTE AT WALNUT CREEK
FACILITY NUMBER: 079201006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 locations: memory care resident room (broken magnetic lock on cabinet) and Lysol cleaner in 2 unlocked cabinets in Country Care Kitchen in memory care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2022
Plan of Correction
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Where residents with dementia live, ALL locking cabinets must be in working order and ALL cabinets have been checked and any possibly injurious cleaning or disinfecting solutions and sharp objects have been made inaccessible to persons in care. Attestation by a manager must be sent to LPA that this task has been completed by the POC due date. Further, plans for staff training within one week on safeguarding residents from such possibly injurious items must also be sent to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
LIC809 (FAS) - (06/04)
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