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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
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


Created By: James Sampair On 04/10/2023 at 04:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 Humpal
LICENSING EVALUATOR NAME:James Sampair
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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