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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201161
Report Date: 07/29/2024
Date Signed: 07/29/2024 02:56:43 PM


Document Has Been Signed on 07/29/2024 02:56 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: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: 3DATE:
07/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator/Licensee Asha JainTIME COMPLETED:
03:15 PM
NARRATIVE
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On 7/29/2024 at 11:15 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to complete the Required Annual Inspection began on 7/26/2024. Upon entry, LPA stated the purpose of the visit to Administrator/Licensee Asha Jain.

The LPA inspected the interior and exterior of the facility. The LPA reviewed facility records and the records of 5 staff members.

1 Type-B citation was issued during the inspection.

Annual inspection complete.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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 07/29/2024 02:56 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: WALNUT CREEK CARE HOME
FACILITY NUMBER: 079201161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a review of the records, the licensee did not comply with the section cited above because of the inadequate or no records of required training for 3 of 5 staff member, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Licensee shall send template for recording staff member training that will be used in the future to the LPA on or before due date.
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: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2