075601419-5-1-2023-15-AS-LAWN-CRELT2-20230501090134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601419
Report Date: 04/27/2023
Date Signed: 05/01/2023 09:02:21 AM

Document Has Been Signed on 05/01/2023 09:02 AM - 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:	HALCYON CARE HOME		FACILITY NUMBER:	075601419
ADMINISTRATOR:	PHAN, MARIVIC V.		FACILITY TYPE:	740
ADDRESS:	1024 MT. VIEW BLVD.		TELEPHONE:	(415) 244-0985
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94596
CAPACITY:	6	CENSUS: 4	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Michael Phan, Licensee		TIME COMPLETED:	03:30 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 04/27/2023 at 10:22 AM, Licensing Program Analysts (LPAs) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Licensee, Michael Phan and explained the purpose of the visit. The facility’s fire clearance was approved for 6. LPAs toured facility with Michael including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 3 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. The facility consists of 3 bathrooms. Indoor and outdoor passageways were free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs 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 118.4 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. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 03/22/2023. Emergency Disaster Plan was last posted on 11/01/2020 . First aid kit was observed to be complete. Emergency disaster drill was last conducted on 03/15/2023. LPA reviewed 4 residents records. LPA reviewed 5 staff records and 3 of 5 have current first aid training and associated to the facility. Continued LIC809-C...

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HALCYON CARE HOME	FACILITY NUMBER: 075601419
	VISIT DATE: 04/27/2023

NARRATIVE

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Continued from LIC 809...

At 10:50 AM LPA observed building materials, wood, tile, paint cans, shed materials for building a shed and 3 doors on the side of the house.
At 10:56 AM LPA observed swing set parts and buckets.
At 10:57 AM LPA observed tires, fish tanks, buckets, gas tank.

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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 05/04/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Surety Bond 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: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2023 09:02 AM - 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: HALCYON CARE HOME	FACILITY NUMBER: 075601419
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

(a) 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. This requirement is not met as evidenced by: Not having tires, fish tanks, flower pots, swing set, buckets, paint cans, doors, shed materials, wood.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 05/11/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will clean the yard and remove all the items: tires, fish tanks, buckets, gas tank, walkers, dollys, netting, swing set, shed materials, tiles, 3 doors, flower pots, paint cans and will send photos 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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