075601304-12-6-2023-15-AS-CFOR-CY9VBA-20231206151712

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601304
Report Date: 12/06/2023
Date Signed: 12/06/2023 03:17:23 PM

Document Has Been Signed on 12/06/2023 03:17 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: 4	DATE:	12/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Priscilla Tapia, Caregiver		TIME COMPLETED:	03:55 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 12/06/2023 at 9:30am, Licensing Program Analyst (LPA) C. Fowler conducted an unannounced 1-Year Required inspection. LPA met with Priscilla Tapia, Caregiver, and explained the purpose of the visit. The Administrator Mia Enriquez arrived at approximately 11:15am. The Administrator currently holds an expired certificate (#6009401740) that expired on 12/01/2023, Administrator provided a copy of documents (education and application) mail for renewal. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 70 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 123.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and nonskid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/28/2023. Emergency Disaster Plan was last reviewed and updated was 05/05/2023. First aid kit was observed to be complete. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TARA HILLS CARE HOME	FACILITY NUMBER: 075601304
	VISIT DATE: 12/06/2023

NARRATIVE

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Continued from LIC809.

LPA observed the following deficiencies:

· At 10:36am, LPA observed water temperature measured at 123.8.
· At 10:40am, LPA observed a commode, 2 mattresses, bed rails, screen doors and soil, brooms, plants, in a chair located in the back yard.
· At 10:46am, LPA observed facility had a bedroom in the garage that is not fire cleared.

LPA requested the following documents to be submitted to CCLD by 12/20/2023.

· 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

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: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2023 03:17 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: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 the water temperature at 123.8 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed to adjust water heater, measure water temperature and provide CCLD a photo of reading no later than POC 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/06/2023 03:17 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: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. 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 items such as commode, mattresses, bed rails, soil, plant, broom in 2 chairs in the back yard which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have items listed removed from the back and side yard no later than the POC date.

Type B

Section Cited

CCR

87307(a)(B)

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on, the licensee did not comply with the section cited above by using a room in the garage for staff sleeping which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Administrator agreed to remove beds, clothing and shoes and use for breakroom/storage which room has been fire cleared for. Administrator will provide photos of room once cleared. Civil penalty of $500 is being assessed for fire clearance 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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