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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201161
Report Date: 04/04/2023
Date Signed: 04/04/2023 05:05:23 PM


Document Has Been Signed on 04/04/2023 05:05 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:WALNUT CREEK CARE HOMEFACILITY NUMBER:
079201161
ADMINISTRATOR:JAIN, ASHAFACILITY TYPE:
740
ADDRESS:2562 VENADO CAMINOTELEPHONE:
(925) 287-8994
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 4DATE:
04/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Caregiver Nestor AvecillaTIME COMPLETED:
05:30 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
During the unannounced complaint inspection at the facility on 04/04/2023, Licensing Program Analyst (LPA) J. Sampair conducted a complaint visit after observing additional deficiencies. LPA discussed these deficiencies with Caregiver Nestor Avecilla during the complaint investigation.
  • Civil penalty issued because of a staff person working who was not associated with facility.
  • Full rails on R1's bed without a physician's order.
  • Staff not wearing a mask

Facility cited for those deficiencies as per Title 22 of the California Code of Regulations listed on the LIC809-D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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 3


Document Has Been Signed on 04/04/2023 05:05 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: WALNUT CREEK CARE HOME
FACILITY NUMBER: 079201161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2023
Section Cited

1
2
3
4
5
6
7
87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).
1
2
3
4
5
6
7
Until Fe Alolod has been associated with the facility, she shall not be allowed to work or volunteer in the facility. On or before the due date, Licensee shall associate Fe Alolod with the facility. Licensee shall inform LPA of successfully associating Fe with the facility.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Staff person Fe Alolod was not associated with facility.
8
9
10
11
12
13
14
Type B
04/04/2023
Section Cited

1
2
3
4
5
6
7
87468.1 PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES (a) Residents ... have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Cleared during inspection when all staff put on masks and Licensee acknowledged that he did not know of that requirement by the Department and the California Department of Public Health.
8
9
10
11
12
13
14
Based on observation by LPA J Sampair on 04/04/2023 at 10:00 AM of ataff S1 not wearing a mask, Licensee failed to protect the personal rights of residents, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/04/2023 05:05 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: WALNUT CREEK CARE HOME
FACILITY NUMBER: 079201161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2023
Section Cited

1
2
3
4
5
6
7
87608 Postural Supports (a) ... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record...
1
2
3
4
5
6
7
Rails on R1's bed removed during visit.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Full railings on R1's bed without a physician's order.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3