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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201218
Report Date: 07/28/2023
Date Signed: 07/28/2023 04:25:08 PM


Document Has Been Signed on 07/28/2023 04:25 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:BYRON PARKFACILITY NUMBER:
079201218
ADMINISTRATOR:RICARDO ROMEROFACILITY TYPE:
740
ADDRESS:1700 TICE VALLEY BLVDTELEPHONE:
(925) 937-1700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:151CENSUS: DATE:
07/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ricardo RomeroTIME COMPLETED:
04:45 PM
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On 07/28/2023 at 1:30 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for a case management visit concerning 6/23/2023 incident reported on 6/29/2023. Upon entering, LPA stated purpose of visit to Administrator (ADM) Ricardo Romero.

During the visit, LPA met with ADM and Resident Care Supervisor (RCS) Danica Aquino.

The ADM explained in detail the errors in communication that precipitated running out of and then not dispensing R1's medication from 06/12/2023 to 06/23/2023, which has been dispensed per doctor's orders since 06/23/2023. The RCS and the Assisted Living Director (ALD) Jessica Gurnack met with Medication Technicians and reviewed the refill protocol. Subsequently, on 07/05/2023, there was a mandatory staff meeting at the facility with retraining as well.

No citations issued during this visit.

Exit interview was conducted with ADM. A copy of this report was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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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