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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200781
Report Date: 05/04/2023
Date Signed: 05/05/2023 11:36:49 AM


Document Has Been Signed on 05/05/2023 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:NEW HAVENFACILITY NUMBER:
079200781
ADMINISTRATOR:ELIZABETH CORTES- PALADFACILITY TYPE:
740
ADDRESS:2236 WHYTE PARK AVENUETELEPHONE:
(510) 965-5555
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 3DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:MARILOU LADABANTIME COMPLETED:
06:30 PM
NARRATIVE
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On 05/04/2023 at 2:15 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Required Annual Inspection. Upon entry, LPA disclosed the purpose of the visit with Lead Staff Marilou Ladaban. At approximately 4:30 PM, Administrator (ADM) Elizabeth Cortes-Palad arrived.

The LPA and Ms. Ladaban toured the facility inside and outside. The inspection was incomplete and will require an additional visit to be complete.

During the inspection, 1 A-Type and 1 B-Type citation were issued (refer to LIC809-D for details). 3 Technical Violations issued for violations of the regulations that do not pose a risk to the health and safety of persons in care.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/11/2023:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610D - Emergency/Disaster Plan
· Evidence of Current Liability Insurance

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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 3


Document Has Been Signed on 05/05/2023 11:36 AM - 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: NEW HAVEN
FACILITY NUMBER: 079200781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(7)(A)
87208 PLAN OF OPERATION (a) Each facility shall have ... current ... (7) Sketches ... of ... (A) Building(s) ... including a floor plan that describes ... uses intended and a designation of the rooms ... for nonambulatory ... residents [and] (B) The grounds showing buildings, driveways, fences, storage areas, pools, gardens, recreation area and other space used by the residents.

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 2 out of 2 facility sketches that were inaccurate, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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On or before due date, Licensee shall send updated sketches to LPA (Floor Plan and Yard Sketches) with the ASSEMBLY POINT added. The updated sketches must include: (A) Buildings with a floor plan that describes: uses intended and a designation of the rooms for nonambulatory and (B) The grounds showing buildings, driveways, fences, storage areas, gardens, recreation area, and other space used by the residents.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/05/2023 11:36 AM - 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: NEW HAVEN
FACILITY NUMBER: 079200781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
87465 INCIDENTAL MEDICAL AND DENTAL CARE SERVICES (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 for all residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Medications returned to original containers during visit.
Section Cited
Deficient Practice Statement
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2
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4
POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3