079201088-1-22-2024-15-AS-JSAR-CZQSRT-20240122130652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201088
Report Date: 01/17/2024
Date Signed: 01/22/2024 01:07:30 PM

Document Has Been Signed on 01/22/2024 01:07 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:	LAFAYETTE RESIDENTIAL CARE		FACILITY NUMBER:	079201088
ADMINISTRATOR:	OPHELIA PEDROSO		FACILITY TYPE:	740
ADDRESS:	1300 JUANITA DRIVE		TELEPHONE:	(925) 945-6833
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94595
CAPACITY:	6	CENSUS: 5	DATE:	01/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Manager Telesha “Ava” Clarke		TIME COMPLETED:	06:30 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 1/17/2024 at 1:45 PM, 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 Caregiver Butch Jerza. Manager Telesha “Ava” Clarke arrived at approximately 2:10 PM. The LPA inspected the facility inside and outside. All outdoor and indoor passageways were free of obstruction. Outside, the pond was inaccessible to residents with dementia. Inside, the temperature was measured at 74.7 degrees Fahrenheit. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the residents. LPA observed 7 days of nonperishable and 2 days of perishable foods on hand. Sharps were stored inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition. Fire extinguisher was observed to be fully charged and last serviced on 3/16/2023. The LPA reviewed the records of 3 residents. 2 Type-A citations and 1 Type-B were issued (for details refer to LIC809-D). By 1/24/2024, 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 Manager. A copy of this report provided via email to the Manager.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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 01/22/2024 01:07 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: LAFAYETTE RESIDENTIAL CARE	FACILITY NUMBER: 079201088
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(b)(2)

Care of Persons with Dementia

(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. 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 in 2 of 2 bathrooms that included mouthwash and hydrogen peroxide in unlocked bathroom cabinets, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/18/2024
	Plan of Correction
1 2 3 4	Corrected during inspection

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in hallway cabinets that were unlocked that had Clorox and other cleaning supplies, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/18/2024
	Plan of Correction
1 2 3 4	Corrected during inspection

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: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/22/2024 01:07 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: LAFAYETTE RESIDENTIAL CARE	FACILITY NUMBER: 079201088
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for all shifts, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Licensee shall conduct emergency / disaster drills for every shift and provide proof on or before due date.

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: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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