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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201006
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:14:09 PM


Document Has Been Signed on 12/20/2023 04:14 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:VIAMONTE AT WALNUT CREEKFACILITY NUMBER:
079201006
ADMINISTRATOR:MELODY MITCHELL ALLENFACILITY TYPE:
741
ADDRESS:2801 SHADELANDS DRIVETELEPHONE:
(925) 954-2600
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:300CENSUS: 254DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director (ED) Melody AllanTIME COMPLETED:
04:30 PM
NARRATIVE
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On 12/20/2023 at 9:45 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Executive Director (ED) Melody Allen.

At 10:15 AM, the LPA began the physical inspection of the facility with Director of Environmental Services Micheal Calhoun. The temperature in the Aspen Room at 10:24 AM was measured at 75.0 and the hot water at 109.4 degrees Fahrenheit. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the residents. In the kitchen, the LPA observed more than the minimum 7 days of nonperishable and 2 days of perishable foods on hand. The Fire Alarm Annual Inspection was completed 10/26/2023 and emergency/disaster drills completed quarterly. All indoor and outdoor passageways were free of obstruction. The swimming pool was inaccessible to residents with dementia.

The LPA reviewed the records of 10 residents.

2 Type-A citations were issued (for details refer to LIC809-D).

By 12/27/2023, Licensee will send updated forms to LPA:
· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance

Required Annual Inspection incomplete. LPA shall return unannounced to complete the inspection at a later date and time. Exit interview conducted with ED Melody Allen. A copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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Document Has Been Signed on 12/20/2023 04:14 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: VIAMONTE AT WALNUT CREEK
FACILITY NUMBER: 079201006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation at 10:30 AM, the licensee did not comply with the section cited above in the Memory Care Kitchen where disinfectant were stored in unlocked cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2023
Plan of Correction
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Licensee made correction during visit.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation at 10:40 AM, the licensee did not comply with the section cited above in Memory Care Room 363 where Febreeze and disinfectant wipes were stored in unlocked cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2023
Plan of Correction
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Licensee made correction during visit.
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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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