075600883-11-14-2024-15-AS-LAWN-DB28W2-20241114215159

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600883
Report Date: 11/14/2024
Date Signed: 11/14/2024 09:54:12 PM

Document Has Been Signed on 11/14/2024 09:54 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:	SUNVALLEY RESIDENTIAL CARE HOME		FACILITY NUMBER:	075600883
ADMINISTRATOR/ DIRECTOR:	MAUER, KEITH M		FACILITY TYPE:	740
ADDRESS:	67 COLLEGE WAY		TELEPHONE:	(925) 323-6428
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	11/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:15 PM
MET WITH:	Keith Mauer, Administrator		TIME VISIT/ INSPECTION COMPLETED:	07:45 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 11/14/2024 at 3:15 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Marjoy Bacuyag and explained the purpose of the visit. Marjoy called Administrator, Keith Mauer, to inform. The administrator arrived 15 mins later. The facility’s fire clearance was approved for capacity of six (6) in which all may be non-ambulatory. Hospice waiver approved for two (2) residents. Administrator Certificate #606274274 expired 08/09/2024. Administrator submit certificate renewal and provided check dated 11/07/2024. LPA toured facility with Keith including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of total six (6) bedrooms which six (6) bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 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 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguishers was last serviced on 02/08/2024. Emergency Disaster Plan was last posted on 01/08/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/28/2024. LIC809-C Continued (Next Page)

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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 11/14/2024 09:54 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: SUNVALLEY RESIDENTIAL CARE HOME	FACILITY NUMBER: 075600883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 inaccessible to residents in a unlocked kitchen drawer which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Administrator locked top kitchen drawer where medications were located unlocked. Administrator agreed to conduct an In-Service Training and submit staff sign-in sheet to CCLD by POC due date.

Section Cited

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 by having a pair of scissors unlocked in top kitchen drawer which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Administrator locked scissors in top kitchen drawer during visit. Administrator agreed to conduct an In-Service Training and submit staff sign-in sheet to CCLD by POC due date. Civil Penalty for $250.00 assessed for repeat violation.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2024 09:54 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: SUNVALLEY RESIDENTIAL CARE HOME	FACILITY NUMBER: 075600883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having annual 20hrs of training for Staff (S) S1-S5 in their files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/12/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit training certificates for S1-S5 to CCLD by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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: SUNVALLEY RESIDENTIAL CARE HOME	FACILITY NUMBER: 075600883
	VISIT DATE: 11/14/2024

NARRATIVE

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LIC809-C Continued...

LPA reviewed four (4) residents records. LPA reviewed five (5) staff records and 5 of 5 have current first aid training and associated to the facility.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 3:32 PM LPA observed unlocked medications and scissors located in top kitchen drawer.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/21/2024:

LIC 308 Designation of Administrative Responsibility - Reviewed
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan - Reviewed
Liability Insurance

Exit interview conducted. Appeal Rights and a copy of 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: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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