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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601562
Report Date: 04/03/2024
Date Signed: 04/03/2024 05:59:51 PM


Document Has Been Signed on 04/03/2024 05:59 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:CORTE VISTA GUEST HOMEFACILITY NUMBER:
075601562
ADMINISTRATOR:BRYSON WRIGHTFACILITY TYPE:
740
ADDRESS:1724 CORTE VISTA STREETTELEPHONE:
(925) 586-6598
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 6DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Bryson Wright AdmnistratorTIME COMPLETED:
06:10 PM
NARRATIVE
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On 04/03/2024 at 1:15PM, Licensing Program Analysts (LPAs) T.Syess-Gibson and G. Luk conducted an unannounced 1-Year Required inspection. LPAs met with Caregiver Jane, spoke with Administrator, Bryson Wright via telephone, and explained the purpose of the visit. The Administrator arrived half hour later and currently holds a certificate (#6011933740) that expires on 08/07/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 72 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 107.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and no skid mats .There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 03/11/2024. Emergency Disaster Plan was last posted on 01/05/2024. First aid kit was observed to be complete. Fire drill was last conducted on 01/05/2024.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CORTE VISTA GUEST HOME
FACILITY NUMBER: 075601562
VISIT DATE: 04/03/2024
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Continued from LIC809.

LPAs reviewed all Six (6) residents and Three (3) staff records and they were current and complete. LPAs reviewed a sample of medications.

LPAs observed the following deficiencies:

· At 1:29pm, LPAs observed an lighter in a unlocked drawer in the kitchen.
· At 1:30pm, LPAs observed unlocked medicine in the refrigerator in the kitchen.

Deficiencies were cited per Title 22 California Code of Regulations and listed on LIC809D. 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.


LPAs requested the following documents to be submitted to CCLD by 04/10/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report (updated)
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance



Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/03/2024 05:59 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: CORTE VISTA GUEST HOME
FACILITY NUMBER: 075601562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a lighter lin an unlocked drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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Administrator locked up lighters during visit. Deficiency cleared.
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having unlcoked medication in the kitchen refridgerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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Administrator locked up medicine during visit. Defiiciency cleared during visit.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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