075600405-8-24-2023-15-AS-LAWN-CV259Z-20230824194622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600405
Report Date: 08/24/2023
Date Signed: 08/24/2023 07:46:31 PM

Document Has Been Signed on 08/24/2023 07:46 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	CLASSIC CARE HOME OF WALNUT CREEK		FACILITY NUMBER:	075600405
ADMINISTRATOR:	QUINTONG, BETH		FACILITY TYPE:	740
ADDRESS:	11 NORLYN DRIVE		TELEPHONE:	(925) 939-4042
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94596
CAPACITY:	6	CENSUS: 5	DATE:	08/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Elena Maria Asuncion, Caregiver		TIME COMPLETED:	08:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 8/24/2023 at 3:30PM, Licensing Program Analysts (LPAs) L. Alexander and L. Hall conducted an unannounced 1-Year Required inspection. LPAs met with Elena Asuncion, Caregiver, and explained the purpose of the visit. Beth Quintong, Administrator, arrived at 5:00 PM. The Administrator certificate #6033318740 and expires 12/21/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) bedrooms and three (3) bathrooms. One (1) of the bedrooms is used by staff. No bodies of water was observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/4/2022. Emergency Disaster Plan was last posted on 11/1/2020. First aid kit was observed to be complete. Fire drill was last conducted on 07/24/2022. Continued on LIC809.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CLASSIC CARE HOME OF WALNUT CREEK	FACILITY NUMBER: 075600405
	VISIT DATE: 08/24/2023

NARRATIVE

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Continued from LIC809.

LPAs reviewed all five (5) resident files and all were in complete. Staff files was not available at facility for review at the time of arrival. Administrator brought staff files with her.

LPA observed the following deficiencies:

At 3:47PM, LPAs observed medicine cabinet unlocked.
At 3:50PM, LPAs observed cabinet underneath kitchen sink with lock, but Lysol, Ajax, and other disinfectants were accessible to residents.
At 3:55PM, LPAs observed facility did not have a seven (7) day of non-perishable and two (2) day of perishable foods available for residents. LPA observed 6 oranges, 2-gallons of milk, no can meat and only 1 can vegetable.
At 3:55PM, LPAs observed medication in refrigerator unlocked
At 4:00PM, LPAs observed during record review all residents files were incomplete.
At 4:20PM, LPAs observed during record review none of the staff files were available for review at facility.

LPA requested the following documents to be submitted to CCLD by 8/31/2023.

Resident Roster
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (9 pages)
Liability Insurance
LIC9282 (Infection Control Plan)

Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CLASSIC CARE HOME OF WALNUT CREEK	FACILITY NUMBER: 075600405
	VISIT DATE: 08/24/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Continued from LIC809C. Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/24/2023 07:46 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CLASSIC CARE HOME OF WALNUT CREEK	FACILITY NUMBER: 075600405
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having scissors, Awesome inaccessible to residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Administrator locked scissors and knives in kitchen drawer during visit. Deficiency cleared during visit.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by not having medications, alcohol, cleaning supplies, toxic chemicals inaccessible to residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Administrator locked cabinet with medication during visit, agreed to place refrigerated medicine in lock box, make gardening supplies and toxins inaccessible, and submit photo to CCLD by POC Due Date.

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/24/2023 07:46 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CLASSIC CARE HOME OF WALNUT CREEK	FACILITY NUMBER: 075600405
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in by having residents' records available and accessible to Licensing and staff which could pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator agreed to complete each resident's file and submit self-certification that each file is complete and submit self-certification to CCLD by POC date.

Type B

Section Cited

CCR

87412(f)

87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect.... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in by having staff records available and accessible which can pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator arrived with staff records during visit. Deficiency cleared during visit.

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/24/2023 07:46 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CLASSIC CARE HOME OF WALNUT CREEK	FACILITY NUMBER: 075600405
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by having ladders, debris, wheelchairs, commodes, furniture, boat inaccessible to residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator shall remove items and send photos to CCLD of items removed by POC Due Date.

Type B

Section Cited

CCR

87555(26)

87555 General Food Service Requirements (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by having fresh veggies, fruits, canned goods and perishable foods available for residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator agreed to purchase food and submit photos of food and receipts to CCLD by POC Due Date.

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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