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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201088
Report Date:
01/06/2023
Date Signed:
01/06/2023 06:37:08 PM
Document Has Been Signed on
01/06/2023 06:37 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 CARE
FACILITY NUMBER:
079201088
ADMINISTRATOR:
OPHELIA PEDROSO
FACILITY TYPE:
740
ADDRESS:
1300 JUANITA DRIVE
TELEPHONE:
(925) 945-6833
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94595
CAPACITY:
6
CENSUS:
4
DATE:
01/06/2023
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Ophelia Pedroso
TIME COMPLETED:
07:00 PM
NARRATIVE
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On 1/6/2023, Licensing Program Analyst (LPA) James Sampair conducted an unannounced post licensing inspection. LPA explained the purpose of the visit to Administrator (ADM) Ophelia Pedroso upon entry
. LPA and ADM inspected the facility inside and out.
The facility has an infection mitigation plan in place, and the Infection Preventionist is
Ophelia Pedroso
. However, the staff are not following
the latest COVID-19 infection control guidance, including masking.
Though they have one central entry point at the front entrance, their visitor's log did have a space for recording visitor's temperature.
There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency water supply was observed but not food supplies. Hot water and facility room temperatures maintained at comfortable temperatures. However, a bathroom sink was completely inoperable. Fire extinguisher fully charged and serviced within the past year and carbon monoxide and smoke detectors operational. Administrator is on site a minimum of 20 hours a week to oversee proper business operation.
Continued on LIC809-D . . .
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/06/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/06/2023
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
6
Document Has Been Signed on
01/06/2023 06:37 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:
LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER:
079201088
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/06/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited above in unlocked drawer in kitchen with scissors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/07/2023
Plan of Correction
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Corrected during inspection.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/06/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/06/2023
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
01/06/2023 06:37 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:
LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER:
079201088
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/06/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.
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 1 out of 5 resident rooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/13/2023
Plan of Correction
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3
4
Licensee shall replace light in bedroom and inform LPA on or before due date.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 2 resident bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/13/2023
Plan of Correction
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Licensee shall place non-skid mat in shower and inform LPA on or before due date.
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:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/06/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/06/2023
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
01/06/2023 06:37 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:
LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER:
079201088
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/06/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 2 resident bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/13/2023
Plan of Correction
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3
4
Licensee shall repair sink in bathroom and inform LPA on or before due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not provide proof that they complied with the section cited above in 2022 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/13/2023
Plan of Correction
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Licensee shall inform LPA on or before due date that they have: (1) purchased and labeled a 72 hour supply of emergency food as being for emergency use only and (2) conducted a quarterly emergency drill.
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:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/06/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/06/2023
LIC809
(FAS) - (06/04)
Page:
4
of
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Document Has Been Signed on
01/06/2023 06:37 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:
LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER:
079201088
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/06/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 exterior gates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/13/2023
Plan of Correction
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2
3
4
Licensee shall install a side gate meeting those requirements and inform LPA on or before due date.
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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 1 of the resident rooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/13/2023
Plan of Correction
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2
3
4
Licensee shall replace or repair the non-functioning auditory device and inform LPA on or before due date.
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:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/06/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/06/2023
LIC809
(FAS) - (06/04)
Page:
5
of
6
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:
LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER:
079201088
VISIT DATE:
01/06/2023
NARRATIVE
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Facility cited for:
A Unlocked drawer in kitchen with scissors.
B Auditory device on exterior door not working.
B Sink in bathroom not draining
B Side gate latch non-operational.
B No designated emergency food supply or proof of 2022 quarterly drills
B Floor mat in only 1 bathroom
B Non-operational light in resident room
Administrator to send updated copies of these documents to CCL on or before 01/013/2023:
LIC500 - Personnel Report
LIC308 - Designation of Facility Responsibility
LIC610D - Emergency/Disaster Plan
Evidence of sufficient Liability Insurance
Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/06/2023
LIC809
(FAS) - (06/04)
Page:
6
of
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