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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201218
Report Date: 12/27/2022
Date Signed: 12/27/2022 07:11:26 PM


Document Has Been Signed on 12/27/2022 07:11 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:BYRON PARKFACILITY NUMBER:
079201218
ADMINISTRATOR:MURRAY, JENNIFERFACILITY TYPE:
740
ADDRESS:1700 TICE VALLEY BLVDTELEPHONE:
(925) 937-1700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:151CENSUS: 88DATE:
12/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gia AronTIME COMPLETED:
06:00 PM
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On 12/27/2022, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a change of ownership prelicensing visit. LPA met with Resident Relations Director Gia Aron and informed her of the reason for the visit. Application is for change in ownership and facility is currently in operation. Fire clearance was granted on 10/27/2022 for 151 total capacity, 141 of whom may be non-ambulatory and 10 bedridden.

LPA toured the facility inside out with Ms. Aron and facility staff members. A central Covid-19 screening for staff and visitors was observed at the facility entrance. Facility has central storage for PPEs. The pool was appropriately fenced and secured. LPA inspected the kitchen, dining areas, restrooms, community living spaces, bedrooms, bathrooms, trash areas, and the exterior of the facility. The facility was appropriately furnished and well lit. Professional grade equipment was installed and maintained for residents/ care. Food supplies were checked and observed to be sufficient and new orders come on a regular basis.

Medications are centrally stored. Bathrooms and showers were observed equipped with grab bars and non-skid mats. Complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council and Rights to Family Council were observed posted in a prominent place. Carbon monoxide and smoke detectors operational. First aid kit inspected. Facility has emergency lighting. Hot water temperature in one of the common areas was tested and measured at 115 degrees Fahrenheit.

LPA issued a citation for fire extinguishers that did not pass inspection (refer to 12/27/2022 LIC 809-D for facility #79200630).

LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application and license to be granted by CAB analyst.

Exit interview conducted and 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: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
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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