079201077-8-3-2022-15-AS-LHAL-CGXUVV-20220803155546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201077
Report Date: 08/03/2022
Date Signed: 08/03/2022 03:56:04 PM

Document Has Been Signed on 08/03/2022 03:56 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:	TREE HOME FOR SENIORS LLC, THE		FACILITY NUMBER:	079201077
ADMINISTRATOR:	SHARMA, VIKRAM VIR		FACILITY TYPE:	740
ADDRESS:	1069 SANTA LUCIA DR		TELEPHONE:	(925) 566-4156
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY:	6	CENSUS: 5	DATE:	08/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Vikram Sharma, Administrator		TIME COMPLETED:	04:05 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 8/3/2022 at 2:25PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Vikram Sharma, Administrator and explained the purpose of the visit. Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, backyard, and kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 118.7 degrees Fahrenheit. Fire extinguisher last serviced on 10/5/2021. There is a minimum of 7-day non-perishables and 2-day perishables foods. During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Infection Control Plan on file. LPA observed PPE, food, and paper supplies are sufficient. Continued on LIC809.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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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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: TREE HOME FOR SENIORS LLC, THE	FACILITY NUMBER: 079201077
	VISIT DATE: 08/03/2022

NARRATIVE

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Continued on LIC809C

The following deficiency was observed:

-At 2:54PM, LPA observed room in garage that is not on facility sketch and staff is residing in the room.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/03/2022 03:56 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: TREE HOME FOR SENIORS LLC, THE	FACILITY NUMBER: 079201077
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(b)

87305 Alterations to Existing Building or New Facilities (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. 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 having the room in the garage on the facility sketch and using it as a staff room which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2022
	Plan of Correction
1 2 3 4	Administrator agreed to submit a new copy of the facility sketch, showing room in garage requesting it be used for staff to reside and LIC200. Sketch will be submitted to CCLD by POC date.

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: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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