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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200290
Report Date: 02/26/2025
Date Signed: 02/26/2025 12:25:12 PM

Document Has Been Signed on 02/26/2025 12:25 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/
DIRECTOR:		DISTEFANO, KAMILLAFACILITY TYPE:
740
ADDRESS:257 NORMANDY LANETELEPHONE:
(925) 516-6665
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Tedra RichardsonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On February 26, 2025 at 08:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct an annual required inspection. The LPA informed Caregiver Rosa Alvarado of the purpose of the visit. Administrator Tedra Richardson arrived at approximately 9:00 AM.

The LPA inspected the inside and outside of the facility. The inspection included the kitchen, dining area, living room, bedrooms, bathrooms, garage, and yard. An adequate amount of food supplies were observed, more than the required minimum of 2 days perishable and 7 days non-perishable food. The central storage for medications was locked. The cleaning supplies and dangerous objects were stored in locked cabinets.

Facility has working smoke and carbon monoxide detectors. Facility conducts disaster/emergency and fire drills on a quarterly basis; records showed that the most recent drill was conducted on February 1, 2025. The fire extinguisher was fully charged and last serviced on November 26, 2024. The indoor temperature was 69.7 degrees Fahrenheit and the maximum hot water temperature was 114.2 degrees Fahrenheit, in the acceptable range.

The LPA reviewed 5 resident and 5 staff records.

Citations for 1 A-Type and 1 B-Type deficiencies were issued (for details refer to LIC 809-D).

Exit interview conducted and a copy of this report provided.
Harpreet HumpalTELEPHONE: (510) 529-9416
James SampairTELEPHONE: (510) 286-4201
DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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Document Has Been Signed on 02/26/2025 12:25 PM - It Cannot Be Edited


Created By: James Sampair On 02/26/2025 at 11:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(6)
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night...

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 1 out of 1 gates, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
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During the inspection, the wire tie locking the gate was removed, clearing the deficiency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 529-9416
LICENSING EVALUATOR NAME:James Sampair
TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/26/2025 12:25 PM - It Cannot Be Edited


Created By: James Sampair On 02/26/2025 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 the facility, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Staff posted signs at the facility entrances, clearing the defiencies during the inspection
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
TELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME:James Sampair
TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
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