<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601444
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:12:49 PM


Document Has Been Signed on 08/30/2023 03:12 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CAMELLIA GARDENFACILITY NUMBER:
075601444
ADMINISTRATOR:SAVIDGE, ROSITAFACILITY TYPE:
740
ADDRESS:2832 MI ELANA CIRCLETELEPHONE:
(925) 945-1237
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Dylan SavidgeTIME 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 08/30/2023 at 09:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility for Required Annual Inspection. LPA stated purpose of the inspection to Licensee Dylan Savidge and Administrator Joy M. Enriquez.

LPA toured facility inside and outside. Facility is clean and safe and well maintained.

LPA reviewed files of 5 residents and 5 staff members and found them to be mostly complete. LPA interviewed 2 staff and 2 residents, and found the staff to be fully competent and the residents to be well cared for.

1 B-Type citation issued during the inspection (refer to LIC809-D for details).

Exit interview conducted with Caregiver Christian Ramos. A copy of this report provided for Licensee Dylan Savidge and Administrator Joy M. Enriquez by LPA via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/30/2023 03:12 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: CAMELLIA GARDEN
FACILITY NUMBER: 075601444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 1 out of 7 staff members, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2023
Plan of Correction
1
2
3
4
Completed during inspection.
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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2