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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201155
Report Date: 09/18/2024
Date Signed: 09/18/2024 03:12:30 PM

Document Has Been Signed on 09/18/2024 03:12 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:TAREYTON HOME, LLCFACILITY NUMBER:
079201155
ADMINISTRATOR/
DIRECTOR:		FARIN DE DIOS, MIGUELAFACILITY TYPE:
740
ADDRESS:9675 TAREYTON AVE.TELEPHONE:
(925) 588-1886
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 6DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Caregiver, Tito Lacuesta JrTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 9/18/2024 at 12:30 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Tito Lacuesta Jr and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory and a hospice waiver for 2. Clients were at day program during visit. LPA spoke with the Administrator over the phone and was told Tito could sign the report.

LPA toured facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 125.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 10/4/2023. Emergency Disaster Plan was last posted on 9/18/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/8/2024.

At 1:00pm, LPA reviewed 6 of 6 residents records. At 1:30pm, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. LPA observed P&I log to be correct and Facility has a sufficient surety bond.

REPORT CONTINUES ON LIC 809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TAREYTON HOME, LLC
FACILITY NUMBER: 079201155
VISIT DATE: 09/18/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 1:51pm LPA observed a box of medications unlocked and unsecured in the sliding door closet by the front door
  • At 1:55pm LPA observed that the facility had been altered and was not matching the approved facility sketch. A door has been installed in room 1 that the staff use to have access to the designated staff room. The approved door has been blocked by a cabinet. Due to alteration clients privacy and personal rights are being violated by staff needing to use their bedroom as a way to access the bathroom and staff room.
  • At 1:57pm LPA measured the hot water temperature and it was 125.1 degrees F.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/18/2024 03:12 PM - It Cannot Be Edited


Created By: Alona Gomez On 09/18/2024 at 02:59 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: TAREYTON HOME, LLC
FACILITY NUMBER: 079201155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in the hot water temperature in the clients shared bathroom measuring at 125.1 F which posed an immediate safety risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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2
3
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Water temperature was fixed by the end of visit and measured at 107. POC clear
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 having a box of unsecured prescription medications in the closet by the front door which posed an immediate safety risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Medications were locked away. POC cleared
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/18/2024 03:12 PM - It Cannot Be Edited


Created By: Alona Gomez On 09/18/2024 at 02:59 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: TAREYTON HOME, LLC
FACILITY NUMBER: 079201155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in altering the placement of the door used to access the staff room which poses personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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By POC Administrator agrees to un-alter the facility to match with the facility sketch and notify CCLD.
Section Cited
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
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