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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200290
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:13:09 PM


Document Has Been Signed on 02/21/2024 02:13 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:A PLACE FOR SENIORS, LLCFACILITY NUMBER:
079200290
ADMINISTRATOR:DISTEFANO, KAMILLAFACILITY TYPE:
740
ADDRESS:257 NORMANDY LANETELEPHONE:
(925) 516-6665
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver Brianna SappTIME COMPLETED:
02:30 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 02/21/2024 at 9:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a required annual inspection. LPA explained the purpose of the visit to Caregiver Brianna Sapp.

LPA toured the interior and exterior of the facility. LPA inspected the kitchen, dining area, restrooms, community living spaces, bathrooms, resident rooms, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the dining room was measured at 79.0 degrees Fahrenheit at 1:04 PM. Fire extinguisher was fully charged and last serviced on 8/7/2023.

Carbon monoxide and smoke detectors were fully operational. The LPA observed postings in the facility that included a complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council, and Rights to Family Council, which were posted in a prominent location.

An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPA reviewed facility records, the records of 5 staff members, and the records of 5 residents. The LPA interviewed 2 staff members and 2 residents.

2 A-Type citations issued during inspection.

Administrator to send updated copies of these documents to CCL on or before 02/29/2024:
  1. LIC500 - Personnel Report
  2. LIC308 - Designation of Financial Responsibility
  3. LIC610D - Emergency/Disaster Plan
  4. Evidence of sufficient Liability Insurance

Exit interview conducted with Licensee. A copy of this report provided to the Licensee via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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 02/21/2024 02:13 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: A PLACE FOR SENIORS, LLC
FACILITY NUMBER: 079200290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the kitchen cabinet under the sink with a broken lock that contained Windex, Liquid Plumber, Hot Shot Flying Insect Spray, and liquid dish soap, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
1
2
3
4
During inspection, Windex, Liquid Plumber, Hot Shot Flying Insect Spray, and liquid dish soap were removed from the cabinet, thereby clearing the citation.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the kitchen wall cabinet with no lock where staff were placing pill boxes with medications in them, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
1
2
3
4
During inspection, the pill boxes with medications in them were moved to the locked medicine closet, thereby clearing the citation.
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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2