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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079200794
Report Date:
11/21/2023
Date Signed:
11/21/2023 04:50:19 PM
Document Has Been Signed on
11/21/2023 04:50 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
OAKLAND ASC
,
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) 705-7841
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94595
CAPACITY:
6
CENSUS:
5
DATE:
11/21/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Administrator Rachelle Perez
TIME COMPLETED:
05:00 PM
NARRATIVE
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On 11/21/2023 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct an annual inspection. Upon arrival, LPA explained the purpose of the visit to Caregiver 1 (C1). Administrator (ADM) Administrator Rachelle Perez arrived at approximately 9:15 AM.
During the Inspection, the LPA inspected the facility inside and outside. All outdoor and indoor passageways were free of obstruction. There were no bodies of water observed. Inside, the temperature was measured at a comfortable 68 degrees Fahrenheit. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the residents. Residents’ bathrooms were observed to be equipped with grab bars and non-skid mats. LPA observed 7 days of nonperishable and 2 days of perishable foods on hand. Sharps and dangerous items were inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition. Fire extinguisher was observed to be fully charged and serviced on 07/12/2023.
LPA interviewed 1 resident, and reviewed facility, staff, and resident records.
4 Type-B citations issued (for details refer to LIC809-D).
Annual inspection is incomplete. The LPA will return at a future date and time to complete the inspection.
Exit interview conducted with ADM. A copy of this report provided via email.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
11/21/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/21/2023
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
Document Has Been Signed on
11/21/2023 04:50 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
OAKLAND ASC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
TICE VALLEY RESIDENTIAL CARE
FACILITY NUMBER:
079200794
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 6 employees, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/05/2023
Plan of Correction
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2
3
4
All current employees must have completed Health Report with TB testing on or before due 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) -62-2621
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
11/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/21/2023
LIC809
(FAS) - (06/04)
Page:
2
of
4
Document Has Been Signed on
11/21/2023 04:50 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
OAKLAND ASC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
TICE VALLEY RESIDENTIAL CARE
FACILITY NUMBER:
079200794
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 5 staff people do not have CPR training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/05/2023
Plan of Correction
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All current employees must have completed CPR training on or before due date.
Type B
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 first aid kits, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/05/2023
Plan of Correction
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4
Licensee shall obtain a complete first aid kit for the facility on or before the due 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) -62-2621
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
11/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/21/2023
LIC809
(FAS) - (06/04)
Page:
3
of
4
Document Has Been Signed on
11/21/2023 04:50 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
OAKLAND ASC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
TICE VALLEY RESIDENTIAL CARE
FACILITY NUMBER:
079200794
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 residents using oxygen equipment, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/05/2023
Plan of Correction
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2
3
4
Licensee shall post signs and submit a written report to local fire jurisdiction that oxygen is in use at the facility.
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) -62-2621
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
11/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/21/2023
LIC809
(FAS) - (06/04)
Page:
4
of
4