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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600405
Report Date: 07/03/2024
Date Signed: 07/03/2024 06:57:52 PM


Document Has Been Signed on 07/03/2024 06:57 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 CREEKFACILITY NUMBER:
075600405
ADMINISTRATOR:QUINTONG, BETHFACILITY TYPE:
740
ADDRESS:11 NORLYN DRIVETELEPHONE:
(925) 939-4042
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:6CENSUS: 3DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Gregorio "Jojo" Condeno, CaregiverTIME COMPLETED:
07:20 PM
NARRATIVE
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On 07/03/2025 at 1:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Gregorio "Jojo" Condeno and explained the purpose of the visit. Licensee/Administrator, Beth Quintong was not available. The facility’s fire clearance was approved for capacity of 6 (six) residents in which all may be non-ambulatory. Hospice waiver approved for 1 (one). Administrator certificate #6033318740 expires 12/21/2024.

LPA toured facility with Jojo including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 (six) total bedrooms which 3 (three) bedrooms are occupied by the residents and 1 (one) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water 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 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/04/2022. Emergency Disaster Plan was not posted. First aid kit was observed to be complete. Emergency disaster drill was not posted..

LIC809-C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9


Document Has Been Signed on 07/03/2024 06:57 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: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 by not conducting fire drills which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator will send fire drill list with participants for each shift to CCLD by POC due date.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

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 by not annually reviewing Emergency Disaster Plan which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator will send a copy of signed LIC610E (page 9) 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9


Document Has Been Signed on 07/03/2024 06:57 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: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(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
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Based on observation, the licensee did not comply with the section cited above in by not having fruits, variety canned foods, meats, snacks, water for residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Administrator will purchase foods and send a photo along with a copy of receipt to CCLD by POC due date. This is a repeat violation and civil penalty is assessed.
Type A
Section Cited
CCR
87705(f)(2)
(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
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Based on observation, the licensee did not comply with the section cited above in by not having refrigerated insulin in lock box, Awesome Bleach, Fabuloso and laundry detergent unlocked and inaccessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Administrator will remove and lock up items, send a photo and send self-certification that they have read and understand the regulation moving forward. Administration will send POC to CCLD by POC due date. This is a repeat violation and civil penalty is assessed.
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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


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: 07/03/2024
NARRATIVE
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LIC809-C Continued...

LPA reviewed 3 residents records. Staff records were not available at the facility.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 2:25pm LPA observed medication in cups unlocked in top kitchen drawer
At 2:30pm LPA observed Awesome Bleach, Fabuloso disinfectant cleaner and laundry detergent unlocked outside in laundry room
At 2:32pm LPA observed a boat, trailer, boxes, chairs, walker, ladders, bike, paint cans and other debris including but not limited to dried leaves, old cans, tools, gardening tools located outside


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/10/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/03/2024 06:57 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: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by not having updated tagged fire extinguishers which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Administrator will send a photo and copy of receipt of tagged fire extinguishers or new fire extinguishers to CCLD by POC 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 07/03/2024 06:57 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: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
87507 Admission Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.


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 by not having Residents (R) R1-R3 Admission Agreements (AD) in their files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator will send copies of R1-R3 AD to CCLD by POC due date.
Type B
Section Cited
CCR
87608(3)
87608 Postural Supports
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.



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 by having a doctor's order for R1-R3 hospitel beds and/or 1/2 rails which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator will send a copy of Doctor's orders for hospital bed and or 1/2 rails for R1-R3 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9


Document Has Been Signed on 07/03/2024 06:57 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: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on interview and record review, the licensee did not comply with the section cited above in by not having staff records available which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator will self-certify that they have read and understand the regulation moving forward and notify CCLD when they have the documents at the facility. Send copies of staff health screening with TB, First Aid/CPR but not limited to CCLD by POC due date. This is a repeat violation and civil penalty is assessed.
Type B
Section Cited
CCR
87307(d)
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
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Based on observation, the licensee did not comply with the section cited above in by not having ladders, paint cans, chairs, walker, hitch trailer and all debris located on the trailer but not limited to, bike, boat, debris, garden soil and boat all located outside backyard which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator will complete a self-certification that they have read and understand the regulation. In addition, all items listed but not limited to needs to be removed and backyard should be clean. Administrator will send a photo of all areas of backyard showing that items are removed to CCLD by POC due date. This is a repeat violation and civil penalty is assessed.
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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 9 of 9