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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201218
Report Date: 04/10/2023
Date Signed: 04/10/2023 05:02:54 PM


Document Has Been Signed on 04/10/2023 05:02 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:
04/10/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Resident Relations Director, Gia AronTIME COMPLETED:
05:15 PM
NARRATIVE
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On 04/10/2023 at 8:40 AM Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct Post-Licensing inspection visit. LPA disclosed the purpose of the visit to staff Melanie Lopez upon entry and met with Resident Relations Director (RSD) Gia Aron at approximately 10:45 AM.

LPA inspected facility, met with staff, and reviewed documents. During inspection of physical plant, at 1:35 PM, hot water measured at 118 and room temperature at 75.4 degrees F in Bistro.

Citation issued for 1 deficiency (refer to LIC 809-D).

Inspection incomplete and will be continued at a future date.

Exit interview conducted with RSD Gia Aron. 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: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
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 04/10/2023 05:02 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: BYRON PARK
FACILITY NUMBER: 079201218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 of 72 criminal record clearance transfers had been completed after new license for facility had been issued, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee shall complete transfer and communicate to LPA J. Sampair 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) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
LIC809 (FAS) - (06/04)
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