079201044-3-28-2024-15-AS-TSGN-D3SUYB-20240328155940

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201044
Report Date: 03/28/2024
Date Signed: 03/28/2024 03:59:49 PM

Document Has Been Signed on 03/28/2024 03:59 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
OAKLAND ASC, 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: 6	DATE:	03/28/2024
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Kimberly Whittle Administrator		TIME COMPLETED:	04:15 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	On 03/28/2024 at 12:55PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and C. Fowler, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with Administrator, Kimberly Whittle and explained the purpose of the visit. Administrator certificate #6067792740 expires 10/11/2025. Administrator Paul Henry Salazar certificate #6056663740 Expires 07/15/2024 arrived at 2:26PM. The facility’s fire clearance was approved for Six (6) Non-ambulatory residents. Facility has hospice waiver for Three (3) residents. LPAs toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 108.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/22/2023. First aid kit was observed to be complete. Fire and Disaster drills conducted quarterly. Continued on LIC809C..

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DEER RIDGE COUNTRY VILLA	FACILITY NUMBER: 079201044
	VISIT DATE: 03/28/2024

NARRATIVE

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continue from LIC 809

LPAs reviewed Medication and conducted Interviews with three (3) residents.

LPAs observed the following deficiency:

At 2:20pm, LPAs observed all resident records are missing appraisal needs and service plans (ANS), Updated Physician Reports (MA), Consent Forms (CF), Emergency Identification (ID) and Personal Rights.

LPAs requested the following documents to be submitted to CCLD by 04/04/2024.

Residents roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

Deficiency is cited per Title 22 California Code of Regulations and listed on Lic 809D.

Exit interview conducted; A copy of this report and appeal rights provided to Administrator

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2024 03:59 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DEER RIDGE COUNTRY VILLA	FACILITY NUMBER: 079201044
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having the follwing documents in residents records appraisal needs and service plans(ANS),Physician Reports (MA), Consent Forms(CF),Emergency Identification(ID)and Personal Rights.which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/08/2024
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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