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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201161
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:37:32 PM


Document Has Been Signed on 05/04/2023 12:37 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: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: 5DATE:
05/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Asha JainTIME COMPLETED:
01:00 PM
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On 05/04/2023 at 8:30 AM, Licensing Program Analyst (LPA) J Sampair arrived unannounced for a Case Management visit. Upon entering the facility, LPA informed Caregiver Norma Solon of the purpose of the visit: rodent control.

During the 04/04/2023 inspection, this LPA had identified and showed rodent feces in a kitchen drawer to Caregiver Norma Solon, but failed to cite the facility. This return to the facility was to cite them. During this inspection of the kitchen, the LPA observed at 8:45 AM that the drawer had been cleaned and sanitized. He did not observe any other rodent droppings. However, he did observe and feel and thick coat of grease and grime on the kitchen drawers and in the cabinets.

LPA and Administrator (ADM) Asha Jain spoke about this briefly over the phone and ADM arrived at approximately 9:30 AM to inspect the kitchen herself. During that time, she acknowledged that the level of grease and grime in and on the drawers and cabinets was unacceptable. She also discovered the likely source of the grease and grime was the absence of a working exhaust fan over the stove.

1 A-Type and 2 B-Type citations issued for the deficiencies above (refer to LIC809-D for details).

Exit interview conducted with ADM by phone 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: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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 05/04/2023 12:37 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: WALNUT CREEK CARE HOME
FACILITY NUMBER: 079201161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2023
Section Cited

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87303 MAINTENANCE AND OPERATION (a) The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement was not met as evidenced by:
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On or before the due date, the Licensee shall have an exhaust fan installed in the kitchen above the stove. When completed, Licensee shall inform LPA.
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Based on observation, there was no exhaust fan in the kitchen, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/11/2023
Section Cited

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87470 Infection Control Requirements (a) A licensee shall ensure that ... (2) Environmental cleaning and disinfection activities shall be ... completed, at a minimum, as follows: (A) Surfaces ... shall be cleaned and disinfected on a regular basis ... [and] when these surfaces are contaminated or visibly soiled. 

This requirement was not met as evidenced by:
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On or before the due date, the Licensee shall completely remove all grease and grime from all cabinets, handles, drawers, inside of cabinets, and all of the contents of those cabinets (including food and any spice containers). When completed, Licensee shall inform LPA.
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Based on observation, inside and outside of kitchen cabinets had a visible and tactile accumulation of grease and grime, which poses a potential health, safety or personal rights risk to persons in care.
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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: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/04/2023 12:37 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: WALNUT CREEK CARE HOME
FACILITY NUMBER: 079201161

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

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87555 GENERAL FOOD SERVICE REQUIREMENTS (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement was not met as evidenced by:
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Licensee had removed rodent feces and disinfected the kitchen drawer before LPA's arrival at the facility today, so citation cleared during inspection.
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Based on LPA observation of rodent feces in kitchen drawer on 04/04/2023 that he had shared with Caregiver Norma Solon, which posed an immediate health, safety or personal rights risk to persons in care.
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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: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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