079200950-4-25-2023-15-AS-LFII-CR8VCE-20230425161900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200950
Report Date: 04/25/2023
Date Signed: 04/25/2023 04:19:07 PM

Document Has Been Signed on 04/25/2023 04:19 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	PLEASANT HILL VILLA HOME CARE 3		FACILITY NUMBER:	079200950
ADMINISTRATOR:	MAGAT, GLICERIA M		FACILITY TYPE:	740
ADDRESS:	1900 HOOVER AVE		TELEPHONE:	(408) 933-8663
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 4	DATE:	04/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Joy Dela Cueva, Administrator		TIME COMPLETED:	04:25 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 4/25/2023 starting at 1:10 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Joy Dela Cueva, Administrator (ADM) and explained the purpose of the visit. Administrators certificate is valid and expires on 6/25/2024. The facility’s fire clearance was approved for all six (6) non- ambulatory residents, of which (1) may be Bedridden and hospice waiver for three (3) residents. Upon entry, LPA observed two (2) staff and four (4) residents present during inspection. Starting at 1:35 PM, LPA toured facility with ADM including but not limited to five (5) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which all 5 bedrooms are private. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents ’ common area bathroom was measured at 110.7 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishables and 2-day supple of perishable foods. Sharps and toxins were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detector were in operating condition. Fire extinguisher was observed last serviced on 8/15/2022. First aid kit was observed to be complete. Continue on Lic809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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: PLEASANT HILL VILLA HOME CARE 3	FACILITY NUMBER: 079200950
	VISIT DATE: 04/25/2023

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Starting at 2:13 PM, LPA reviewed 3 of 3 staff records. At 2:45 PM, LPA reviewed 4 of 4 residents' records which are current. At 3:17 PM, LPA reviewed a sample of 4 of 4 residents' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/2/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 Pages)
· Liability Insurance

No deficiencies cited during visit.

Exit interview conducted with ADM, and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

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