079200794-11-18-2021-15-AS-JSAR-C8W4JV-20211118180923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200794
Report Date: 11/18/2021
Date Signed: 11/18/2021 06:13:10 PM

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:	TICE VALLEY RESIDENTIAL CARE		FACILITY NUMBER:	079200794
ADMINISTRATOR:	SANTIAGO, RACHELLE H		FACILITY TYPE:	740
ADDRESS:	2206 TICE VALLEY BLVD		TELEPHONE:	(925) 658-8942
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94595
CAPACITY:	6	CENSUS: 5	DATE:	11/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rachelle Santiago		TIME COMPLETED:	01:41 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	Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator, Licensee, and Infection Control Leader Rachelle Santiago. LPA observed 3 staff wearing face masks during visit. Facility has a completed COVID-19 mitigation plan (LIC 808) in place dated 03/12/2021. LPA discussed the LIC 808 with administrator and reviewed up-to-date COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check is done at entry for all staff, residents, and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Ms. Santiago has conducted staff training on infection prevention, symptoms, transmission and proper donning and doffing of PPE. All staff and residents are fully vaccinated. There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper & PPE supplies were observed stored in the facility. Facility room temperature was maintained at a comfortable level and the hot water temperature was within the safe 105 to 120 degree range. A certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged and Smoke and Carbon monoxide detectors were operational. Though pathways were free of obstruction and fire hazards, there was junk in the back yard and physical plant repairs needed that were cited as Type B. Exit interview conducted and a copy of this report was provided to the administrator.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TICE VALLEY RESIDENTIAL CARE	FACILITY NUMBER: 079200794
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 because of the junk in the back yard on the ground, and because of the hazards created from the deteriorating physical plant that includes: rotted flooring and broken railings in the decking in ALL regions of the property, missing and ill-fitting gate latches, tripping hazards in the cement walkways, at least 6 doors inside and out that will not properly close, and at least 3 kitchen drawers coming apart, which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2021
	Plan of Correction
1 2 3 4	Provide proof in the form of pictures to LPA Sampair that all of the junk has been removed from the back yard and that the repairs inside and outside have been completed.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC809 (FAS) - (06/04)

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