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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201044
Report Date: 03/21/2023
Date Signed: 03/21/2023 05:22:54 PM


Document Has Been Signed on 03/21/2023 05:22 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:DEER RIDGE COUNTRY VILLAFACILITY NUMBER:
079201044
ADMINISTRATOR:SALAZAR, HENRYFACILITY TYPE:
740
ADDRESS:419 DEL MONTE COURTTELEPHONE:
(925) 997-7354
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 6DATE:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Paul Henry Salazar, AdministratorTIME COMPLETED:
05:40 PM
NARRATIVE
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On this day at around 11:15AM, Licensing Program Analyst (LPA) L. Ibo arrived at the facility to conduct annual required inspection. LPA was met by caregiver S2. Administrator Paul henry Salazar arrived at around 11:30AM.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, garage dining and living areas. The facility has 4 bedrooms and 2 bathrooms. One bedroom is designated as staff room. There are 6 residents observed. Facility has an approved fire clearance for 6 non ambulatory residents. Two fire extinguishers last serviced in February 2023 were observed.

Facility has sufficient supply of perishable and non-perishable foods. There are 2 staff working during the visit and both are fingerprint cleared. Bathrooms were observed with grab bars and nonskid mats.

LPA reviewed 3 resident and 3 staff files and interviewed 3 residents and 2 staff. Facility has wired carbon monoxide and smoke detector that were observed functional. Facility has a current liability insurance.

At approximately 11:27AM, LPA observed disinfectants unlocked under the sink. At approximately 11:30am, LPA observed cleaning chemicals unlocked in the garage. At 11:31AM LPA observed, unlocked knives and scissors at the kitchen drawer.

At approximately 12:12PM LPA observed hot water measured at 138F. At approximately 12:15PM, LPA observed that tap water temperature was measured at 135F-138F.

Deficiencies are being cited today in violation of California Code of Regulations and follows on 809D. Failure to submit proof of corrections (POC's) along with LIC9098 by plan of correction due dates may result in civil penalty. Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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 3


Document Has Been Signed on 03/21/2023 05:22 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023

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, the licensee did not comply with the section cited above in staff failed to lock disinfectant and sharp objects such as knives and scissors, which were accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2023
Plan of Correction
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Staff locked the disinfectant , knives and scissors. Cleared and corrected during the visit.
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: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/21/2023 05:22 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 licensee failed to regulate hot water at the two bathroom sink, LPA observed 138F temperature, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2023
Plan of Correction
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Corrected during visit. Administrator adjusted the hot water temperature. LPA measured the water, reading was 122F.
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

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 licensee failed to regulate tap water at maximum 125F, LPA observed tap water ranging 135-138F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2023
Plan of Correction
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Corrected during visit. Administrator adjusted the hot water temperature, LPA measured the water, reading was 122F.
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: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3