<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201088
Report Date: 09/26/2022
Date Signed: 09/26/2022 03:37:02 PM

Document Has Been Signed on 09/26/2022 03:37 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:LAFAYETTE RESIDENTIAL CAREFACILITY NUMBER:
079201088
ADMINISTRATOR:MCGILL, TAMRAFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 4DATE:
09/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Ophelia Pedroso, Assistant AdministratorTIME COMPLETED:
03:40 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 9/26/2022 at 2:40PM Licensing Program Analysts (LPAs) L. Hall and C. Fowler arrived unannounced to conduct a Case Management visit. LPA met with Ophelia Pedroso, Assistant Administrator, who arrived at 2:55PM and explained the purpose of the visit.

When LPA L. Hall was conducting a complaint investigation (15-AS-20200317164454) on 9/07/2022 and 09/26/2022, LPA observed S1 was not present at facility. LPA requested staff to contact S1 on visit date 9/07/2022 and was told there was not an answer. LPA requested the LIC500 received it by email on 9/09/2022 and observed it stated S1 was on-call and did not have any specific hours to be present.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

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

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/26/2022 03:37 PM - It Cannot Be Edited


Created By: Laura Hall On 09/26/2022 at 03:17 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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 079201088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2022
Section Cited
CCR
87405(a)

1
2
3
4
5
6
7
87405 (a) All facilities shall have a qualified... administrator... The administrator... shall be on the premises a sufficient number of hours.... The Department may require that the administrator devote additional hours in the facility... This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to update the LIC500 to reflect days and hours that Administrator will be present at the facility. Review regulation 87405 Administrator – Qualifications and Duties and submit a self-certification that the regulation has been reviewed and administrator will abide by the regulation going forward. Self-certification and updated LIC500 will be submitted by the POC date.
8
9
10
11
12
13
14
Based on LPAs observation the Licensee did not comply with the section cited above in the Administrator being on premises a sufficient amount of hours, which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2