079200613-9-13-2023-15-AS-LAWN-CVN2ZB-20230913175004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200613
Report Date: 09/13/2023
Date Signed: 09/13/2023 05:50:29 PM

Document Has Been Signed on 09/13/2023 05:50 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	LAS JUNTAS HOME		FACILITY NUMBER:	079200613
ADMINISTRATOR:	YAMSUN, BANAAG F		FACILITY TYPE:	740
ADDRESS:	121 LAS JUNTAS WAY		TELEPHONE:	(925) 954-8839
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY:	4	CENSUS: 4	DATE:	09/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Banaag Yamsuan, Administrator		TIME COMPLETED:	06:10 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 9/13/2023 at 3:15 PM, Licensing Program Analysts (LPAs) L. Alexander and L. Hall, conducted an unannounced 1-Year Required inspection. LPAs met with Banaag Yamsuan, Administrator, and explained the purpose of the visit. The Administrator holds a certificate #6053359740 which expires on 11/11/2023. The facility’s fire clearance is approved for four (4) non-ambulatory residents. LPAs toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) bedrooms and two (2) bathrooms. No bodies of water was observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPAs 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 110 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. 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 last serviced on 08/18/2023. Emergency Disaster Plan was last posted on 01/23/2023. First aid kit was observed to be complete. Fire drill was last conducted on 04/11/2023. Continued on LIC809.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAS JUNTAS HOME	FACILITY NUMBER: 079200613
	VISIT DATE: 09/13/2023

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
26
27
28
29
30
31
32

Continued from LIC809.

LPAs reviewed six (6) staff files all staff had current first aid certification. LPAs also reviewed all four (4) residents' files which were current and complete.

LPAs observed the following deficiencies:

At 3:56 PM, LPAs observed during rodent/mouse dropping in bottom kitchen drawer.
At 4:11 PM, LPAs observed pink wheelchair chair in outside backyard
At 4:12 PM, LPAs observed broken chest drawers, canvas picture, broken furniture, wood planks, broken white cabinet and carcass prop located outside in front yard

LPAs requested the following documents to be submitted to CCLD by 09/20/2023.

Resident Roster
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (last page)
Liability Insurance
Facility sketch

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 09/13/2023 05:50 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAS JUNTAS HOME	FACILITY NUMBER: 079200613
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onob servation, the licensee did not comply with the section cited above in by not having kitchen cabinets cleaned of rodent droppings which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	Administrator agreed to schedule an appointment with pest control for inside facility and submit invoice to CCLD by POC date.

Type B

Section Cited

CCR

87307(d)(6)

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 not having outside front and back yards cleaned with wheelchairs, broken furniture, animal carcass props which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	Adminstrator agreed to have items removed from the yards and submit photo to CCLD by POC date.

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 Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4