<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201161
Report Date:
07/27/2023
Date Signed:
07/27/2023 05:13:17 PM
Document Has Been Signed on
07/27/2023 05:13 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:
WALNUT CREEK CARE HOME
FACILITY NUMBER:
079201161
ADMINISTRATOR:
JAIN, ASHA
FACILITY TYPE:
740
ADDRESS:
2562 VENADO CAMINO
TELEPHONE:
(925) 287-8994
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94598
CAPACITY:
6
CENSUS:
6
DATE:
07/27/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:50 AM
MET WITH:
Nestor Avecilla
TIME COMPLETED:
05:30 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 07/27/2023 at 08:50 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced at facility for required annual inspection. LPA was greeted by staff member Nestor Avecilla. Licensee Asha Jain arrived at approximately 12:30 PM.
During the Inspection, LPA observed that the facility has a sufficient supply of food: 2 days perishable and 7 days nonperishable. A comfortable inside temperature of 75 was maintained. The facility was well maintained, and clean.
LPA interviewed 2 residents,1 staff member, and reviewed the records for 5 residents and 5 staff members.
The annual inspection of the facility is incomplete and the LPA will return at a later date.
3 B-Type citations were issued during visit.
Exit interview conducted with Licensee and a copy of this report was 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:
07/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
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
07/27/2023 05:13 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:
WALNUT CREEK CARE HOME
FACILITY NUMBER:
079201161
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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 fire extinguisher that was last serviced on 11/30/2021, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/03/2023
Plan of Correction
1
2
3
4
Licensee shall send proof to LPA that the fire extinguisher has been services on or before the 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:
07/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
2
of
4
Document Has Been Signed on
07/27/2023 05:13 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:
WALNUT CREEK CARE HOME
FACILITY NUMBER:
079201161
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87415(a)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:
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 in 2 out of 2 night staff because their first aid and CPR certification has expired, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/03/2023
Plan of Correction
1
2
3
4
Licensee shall send proof to LPA on or before due date that all night staff have erned their first aid and CPR certificates.
Section Cited
Incidental Medical and Dental Care Services
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:
07/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
3
of
4
Document Has Been Signed on
07/27/2023 05:13 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:
WALNUT CREEK CARE HOME
FACILITY NUMBER:
079201161
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(2)
Incidental Medical and Dental Care Services
(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.
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 in 1 out of 6 residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/10/2023
Plan of Correction
1
2
3
4
Licensee shall send proof to LPA on or before due date that the resident R1 has completed her annual physical and that a new physician's report has been completed.
Section Cited
Care of Persons with Dementia
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:
07/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
4
of
4