079201044-3-1-2021-15-AS-PSIH-BYQ6HV-20210301195010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201044
Report Date: 03/01/2021
Date Signed: 03/01/2021 07:51:01 PM

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:	DEER RIDGE COUNTRY VILLA		FACILITY NUMBER:	079201044
ADMINISTRATOR:	SALAZAR, HENRY		FACILITY TYPE:	740
ADDRESS:	419 DEL MONTE COURT		TELEPHONE:	(925) 997-7354
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 0	DATE:	03/01/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Paul Henry Salazar, Applicant/Administrator		TIME COMPLETED:	03:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Praveen Singh and Jacob Williams conducted a scheduled Pre-Licensing inspection. Due to the Governor's present shelter in place order, this inspection was completed via video-conference with Applicant/Administrator Paul Henry Salazar. A fire safety inspection was completed on 2/3/21, and the home was granted a fire clearance for six (6) non-ambulatory residents. Observations today included, but were not limited to the following: LPAs toured facility inside and out, including bedrooms, bathroom, living room, kitchen, dining area, laundry/storage room, and outside areas. The home was clean, well ventilated, and maintained at a comfortable temperature. This facility has six private resident bedrooms, and one resident bathroom. The facility includes one staff bathroom and a staff break room. Posted material included a facility sketch, Emergency Disaster Plan (610E), Administrator's Certificate, right to council, and If you See Something…CCL Complaint poster. Ombudsman poster and Resident Personal Rights will be posted prior to admitting residents to the facility. LPAs observed locked cabinets designated for centrally stored medications, and staff and resident files. The Administrator stated that appropriate staff will be hired prior to accepting residents, with at least one awake staff during the night. LPA observed a sufficient supply of dishes and utensils. The facility has locked cabinets to store cleaning supplies, disinfectants, and sharps. LPA observed fire extinguishers, smoke detectors, working auditory signals, first aid kit, carbon monoxide detector, a fire safety door, and exit signs. LPA observed fire extinguisher was purchased on 1/6/21 and the hallways were equipped with automatic night-lights. See LIC809-C for continued report.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

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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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: DEER RIDGE COUNTRY VILLA	FACILITY NUMBER: 079201044
	VISIT DATE: 03/01/2021

NARRATIVE

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LPAs observed resident bathroom was equipped with non-skid mats and there were grab bars near the toilet and showers. Hot water temperature in a resident bathroom measured at 120 degrees F. Each resident bedroom was inspected and observed to have the required furniture, and extra linens were available.
LPA observed common area was equipped with appropriate activities for the residents. The outdoor area was observed to be clutter free and well maintained. There were no dangerous items, or bodies of water observed. Patio furniture, and shade were available for residents.

LPAs observed Personal Protective Equipment (PPE) for residents, staff and visitors and a PPE station to monitor and record all incoming visitors.

LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

See LIC809 (Case Management Report) dated 3/1/21, for Comp III Review conducted today.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

LIC809 (FAS) - (06/04)

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