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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201088
Report Date: 01/18/2023
Date Signed: 01/18/2023 06:51:44 PM


Document Has Been Signed on 01/18/2023 06:51 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:OPHELIA PEDROSOFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 4DATE:
01/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Telesha ClarkeTIME COMPLETED:
07:15 PM
NARRATIVE
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On 01/18/2023, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced Plan of Correction (POC) inspection. Upon entry into the facility, the LPA identified himself and the purpose of the visit to staff. Administrator Consultant Telesha Clarke arrived and toured the facility with LPA.

All 6 of the 6 POCs were cleared from the 01/06/2023 inspection.

Two citations were issued. Refer to LIC809D.

A copy of this report was provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
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 2


Document Has Been Signed on 01/18/2023 06:51 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: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2023
Section Cited

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(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:

3 of the 3 exterior auditory devices turned off.
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Licensee shall: (1) ensure that an audiory device is installed on the staff exit door and (2) train staff to keep auditory devices functional at all times. Administrator will attest to the completion of the training to LPA on or before the due date.
Type B
01/25/2023
Section Cited

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(a) Living accommodations and grounds shall ... provide comfortable living accommodations and privacy for the residents

This requirement is not met as evidenced by:

Bedroom #5 is being used as a passageway to the backyard.
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Licensee shall: (1) unlock the staff room to provide access to the backyard and (2) train staff to use the Staff Room as the access into the backyard for themselves and for the other residents.

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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2