075601406-1-3-2025-15-AS-LAWN-DCL3W4-20250103173607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601406
Report Date: 01/03/2025
Date Signed: 01/03/2025 05:36:22 PM

Document Has Been Signed on 01/03/2025 05:36 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:	LA CASA VERDE		FACILITY NUMBER:	075601406
ADMINISTRATOR/ DIRECTOR:	ALCANTARA, LEONARDO		FACILITY TYPE:	740
ADDRESS:	1405 CAMINO VERDE		TELEPHONE:	(925) 285-5078
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 1	DATE:	01/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:05 PM
MET WITH:	Leonardo Alcantara, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:45 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 01/03/2025 at 3:05 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Leonardo Alcantara, Jr. and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of six (6) residents and non-ambulatory. Hospice waiver approved for one (1). Administrator certificate #7010842740 expires 10/04/2025. LPA toured facility with Leonardo including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six (6) total bedrooms which five (5) bedrooms are occupied by the residents and one (1) 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 78 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 110.5 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. Centrally stored medication and sharps were locked and inaccessible to residents. LIC809-C Continued...

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

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: LA CASA VERDE	FACILITY NUMBER: 075601406
	VISIT DATE: 01/03/2025

NARRATIVE

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LIC809-C (Page 2)

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/05/2023. Emergency Disaster Plan was not available. First aid kit was observed to be complete. Emergency disaster drill was not available.

LPA reviewed one (1) resident's records. LPA reviewed two (2) staff records and 1 of 2 have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/10/2025:

LIC 308 Designation of Administrative Responsibility - Reviewed
LIC 309 Administrative Organization - Reviewed
LIC 500 Personnel Report - Reviewed
Updated LIC 610E Emergency Disaster Plan
Liability Insurance - Reviewed
Current Administrator’s Certificate - Reviewed

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.

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: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/03/2025 05:36 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: LA CASA VERDE	FACILITY NUMBER: 075601406
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2025

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 interview and record review, the licensee did not comply with the section cited above in by not having 20hrs annual training for S2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit completed trainings and send a copy of certificates for S2 to CCLD by POC due date.

Section Cited

Personal Rights of Residents

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility. 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 personal rights posted which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit a photo of Personal Rights posted 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/03/2025 05:36 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: LA CASA VERDE	FACILITY NUMBER: 075601406
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. 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 an appraisal and care plan for R1 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit copy of Appraisal Needs and Services for R1 to CCLD by POC due date.

Section Cited

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
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in by not conducting emergency fire drills which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit self-certification that they read and understand this regulation and will comply moving forward. In addition, send a copy of fire drill completed with staff 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC809 (FAS) - (06/04)

Page: 3 of 10

Document Has Been Signed on 01/03/2025 05:36 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: LA CASA VERDE	FACILITY NUMBER: 075601406
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by not having fire extinguishers updated with current fire tags which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/06/2025
	Plan of Correction
1 2 3 4	Administrator agreed to send a copy of receipt and photo of updated fire tags to CCLD by POC due date.

Section Cited

87411 Personnel Requirements - General (c) All RCFE staff who assist residents...shall receive initial and annual training. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 S2 not having current First Aid and CPR on file which poses a potential health, safety risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit copy of First Aid and CPR certifications for S2 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC809 (FAS) - (06/04)

Page: 9 of 10

Document Has Been Signed on 01/03/2025 05:36 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: LA CASA VERDE	FACILITY NUMBER: 075601406
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in by not having an updated Emergency Disaster Plan completed and signed (LIC 601E) which poses a potential health and safety risk to persons in care..
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit to CCLD an updated LIC 610E by POC due date.

Section Cited

Injections. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidence by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by not having a skilled health professional administering insulin injections to R1 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit an copy of an updated medical assessment and doctor's order that shows that R1 can administer their own glucose testing and insulin injections. Documents to be send 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC809 (FAS) - (06/04)

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