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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201153
Report Date: 08/26/2024
Date Signed: 08/26/2024 01:49:36 PM

Document Has Been Signed on 08/26/2024 01:49 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:STRAWBERRY HILL AT GILL PORTFACILITY NUMBER:
079201153
ADMINISTRATOR/
DIRECTOR:		WARD, WHITNEYFACILITY TYPE:
740
ADDRESS:2069 GILL PORT LNTELEPHONE:
(415) 710-5169
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator Mary AsilumTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 8/26/2024 at 9:15 AM, Licensing Program Analysts (LPAs) J Sampair and P Manalo arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Administrator Mary Asilum.

The LPAs inspected the interior and exterior of the facility. The inspection of the physical plant included the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the dining room was measured at 70.7 degrees Fahrenheit at 1:36 PM. The fire extinguisher was replaced 5/3/2024.

The carbon monoxide and smoke detectors were fully operational. The LPAs observed required postings in the facility, including the Residential Care Facility for the Elderly Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

The LPAs reviewed facility records, records of 5 residents, and records of 5 staff members. LPAs Interviewed 2 residents and 2 staff members.

1 citation was issued during the inspection.

Licensee will send proof of Liability Insurance to the LPA by 9/3/2024.

Exit interview conducted and a copy of this report provided.
Harpreet HumpalTELEPHONE: (510) 529-9416
James SampairTELEPHONE: (510) 286-4201
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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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Document Has Been Signed on 08/26/2024 01:49 PM - It Cannot Be Edited


Created By: James Sampair On 08/26/2024 at 01:18 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: STRAWBERRY HILL AT GILL PORT
FACILITY NUMBER: 079201153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

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 the garage where 2 staff were using it as a bedroom, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2024
Plan of Correction
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Licensee shall remove the staff members and all of their personal belongings.
Section Cited
Care of Persons with Dementia
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Humpal
TELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME:James Sampair
TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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