079200738-1-26-2024-15-AS-LAWN-CZV3KM-20240126171923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200738
Report Date: 01/26/2024
Date Signed: 01/26/2024 05:19:32 PM

Document Has Been Signed on 01/26/2024 05:19 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:	PLEASANT HILL VILLA HOME CARE 2		FACILITY NUMBER:	079200738
ADMINISTRATOR:	MAGAT, GLICERIA		FACILITY TYPE:	740
ADDRESS:	2968 BONNIE LANE		TELEPHONE:	(408) 933-8663
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 5	DATE:	01/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Joy Dela Cueva, Administrator		TIME COMPLETED:	05:30 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 01/26/2024 at 1:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Joy Dela Cueva and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) non-ambulatory. Hospice waiver for three (3) residents. Administrator Certificate #6016749740 Expires 06/25/2024. LPA toured facility with Joy including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. 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 116.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/30/2023. Emergency Disaster Plan was last posted on 01/10/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 12/15/2023. LIC809 Continued...

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PLEASANT HILL VILLA HOME CARE 2	FACILITY NUMBER: 079200738
	VISIT DATE: 01/26/2024

NARRATIVE

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LIC809-C Continued...

LPA reviewed 5 residents records. LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

LPA observed during file review that facility had 1 more resident than the approved hospice waiver for 3 residents.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/02/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

Exit interview conducted. Appeal Rights and a copy of 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: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/26/2024 05:19 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: PLEASANT HILL VILLA HOME CARE 2	FACILITY NUMBER: 079200738
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(a)

87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have .... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in by not having an hospice waiver exception for R4 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2024
	Plan of Correction
1 2 3 4	By POC date, Administrator will submit to CCL request for additional hospice waiver. Deficiency will not be cleared until all supporting documents and exception waiver is approved.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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