075601304-10-8-2024-15-AS-CFOR-D9V2QY-20241008173642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601304
Report Date: 10/08/2024
Date Signed: 10/08/2024 05:37:16 PM

Document Has Been Signed on 10/08/2024 05:37 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:	TARA HILLS CARE HOME		FACILITY NUMBER:	075601304
ADMINISTRATOR:	ENRIQUEZ, MIA		FACILITY TYPE:	740
ADDRESS:	908 TARA HILLS DRIVE		TELEPHONE:	(510) 910-6165
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	6	CENSUS: 5	DATE:	10/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Rochelle Sicat Lead Caregiver		TIME COMPLETED:	06:30 PM

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On 10/06/2024 at 2:55 PM, Licensing Program Analysts (LPAs) David Doidge and Carol Fowler arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Rochelle Sicat Lead Caregiver.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts located in med rooms. Smoke detectors and carbon monoxide detectors were observed in working condition. Fire extinguishers were observed to be full and last serviced on 04/28/2023. Temperature in the facility was measured at 70.0 degrees Fahrenheit at 03:00 PM. Water temperature is 110.5 degrees Fahrenheit.

The LPAs observed required postings in the facility, including the Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction.

One week of nonperishable and 2 days of perishable food and water supplies were available.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TARA HILLS CARE HOME	FACILITY NUMBER: 075601304
	VISIT DATE: 10/08/2024

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continue from LIC809

LPA observed the following deficiencies:

· At 3:00pm, LPA observed a lighter located in a kitchen drawer.
· At 3:10pm, LPA observed a 3 residents bedrooms and kitchen doors without screens.
· At 3:30pm, LPA observed staff room being used as living quarters.

LPA requested the following documents to be submitted to CCLD by 10/15/2024.

· 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

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $500.00 civil penalty will be assessed on today's date for associations.*

Exit interview conducted. A copy of the LIC421IM, this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/08/2024 05:37 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TARA HILLS CARE HOME	FACILITY NUMBER: 075601304
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

(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 by having a lighter located in an unlocked kitchen drawer which poses a potential health and, safety risk to persons in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Administrator agreed to keep all lighters locked at all times. DEFICIENCY CLEARED DURING VISIT

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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/08/2024 05:37 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TARA HILLS CARE HOME	FACILITY NUMBER: 075601304
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

All window screens shall be clean and maintained in good repair. LPA's observed room #1 no sliding glass door screen, #2 no sliding glass door screen , #3 no sliding door screen. kitchen sliding door no sliding glass door screen. 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 by not having screen on the sliding doors which poses a potential health and safety or risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	,Administrator agreed to replace all screen on the sliding glass doors.

Type B

Section Cited

CCR

87208(A)

Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation staff is using the staff room for living quarters which poses a potential health and, safety or personal risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Administrator agreed not to allow staff to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date. civil penalty 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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

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