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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601533
Report Date:
05/19/2023
Date Signed:
05/19/2023 06:11:37 PM
Document Has Been Signed on
05/19/2023 06:11 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:
CAMELLIA GARDEN II
FACILITY NUMBER:
075601533
ADMINISTRATOR:
SAVIDGE, ROSITA
FACILITY TYPE:
740
ADDRESS:
390 EL DIVISADERO AVENUE
TELEPHONE:
(925) 457-5942
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94598
CAPACITY:
6
CENSUS:
6
DATE:
05/19/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Rosita Savidge
TIME COMPLETED:
06:30 PM
NARRATIVE
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On 05/19/2023 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Required Annual Inspection. Upon entry, LPA disclosed the purpose of the visit with Administrator (ADM) Rosita Savidge.
The LPA and ADM toured the facility inside and outside. The inspection was incomplete and will require an additional visit to be complete.
During the inspection, 3 B-Type citations and 1 Civil Penalties were issued (refer to LIC809-D and LIC421IM for details).
Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/19/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/19/2023
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
3
Document Has Been Signed on
05/19/2023 06:11 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:
CAMELLIA GARDEN II
FACILITY NUMBER:
075601533
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/19/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Licensee had no copy on hand of the fire clearance.
POC Due Date:
05/30/2023
Plan of Correction
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2
3
4
Licensee shall print and display fire clearance.
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above and has a fire clearance for 6 ambulatory, 2 nonambulatory, and 0 bedridden residents but currently has 5 nonambulatory residents and had accepted 1 new resident into the facility in 2020 who was bedridden at the time, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2023
Plan of Correction
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2
3
4
Licensee shall submit an LIC200 requesting a fire clearance inspection to increase the number of nonambulatory to 6.
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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/19/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/19/2023
LIC809
(FAS) - (06/04)
Page:
2
of
3
Document Has Been Signed on
05/19/2023 06:11 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:
CAMELLIA GARDEN II
FACILITY NUMBER:
075601533
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/19/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87705(c)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
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 by not complying with nonambulatory fire clearance for each room that is being used to accommodate a resident with dementia who is unable to or unlikely to
respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2023
Plan of Correction
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2
3
4
Licensee shall submit an LIC200 requesting a fire clearance inspection to increase the number of nonambulatory to 6.
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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/19/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/19/2023
LIC809
(FAS) - (06/04)
Page:
3
of
3