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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600693
Report Date: 12/30/2022
Date Signed: 12/30/2022 01:09:23 PM

Document Has Been Signed on 12/30/2022 01:09 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 MANORFACILITY NUMBER:
015600693
ADMINISTRATOR:RICHARD W. GINDLESBERGERFACILITY TYPE:
740
ADDRESS:27794 PLEASANT HILL CTTELEPHONE:
(510) 581-3557
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 5DATE:
12/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:RICHARD W. GINDLESBERGER- AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
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On 12/29/2022, at 9:25 AM, Licensing Program Analyst (LPA) Liridon Fici and Jill Clancy-Czuleger arrived unannounced to conduct an Annual Infection Control Visit. LPAs was greeted by RICHARD W. GINDLESBERGER, Administrator and explained the purpose of todays visit.

During the inspection, LPAs toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. Common areas are disinfected frequently throughout the day. Water temperature is measured at 112.5 Degrees F in common area bathroom. Fire extinguisher was last serviced on 6/8/2022. Facilities room temperature is maintained at 68 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are functional.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

1. At 9:35 AM, LPAs observed a damaged and unrepaired refrigerator located in the garage.


Continue on Lic809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2022
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 MANOR
FACILITY NUMBER: 015600693
VISIT DATE: 12/30/2022
NARRATIVE
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Continued from Lic809

2. At 9:40 AM, LPAs observed an insufficient supply of food.

3. At 9:50 AM, LPAs observed a board that blocks the stairs going upstairs into the living room and a piece of wood that's blocking the backyard gate.

4. At 9:55 AM, LPAs observed unlocked knifes in the kitchen that is accessible to residents in care.

Exit interview conducted with Administrator, appeal rights given and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/30/2022 01:09 PM - It Cannot Be Edited


Created By: Liridon Fici On 12/30/2022 at 12:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PLEASANT HILL MANOR
FACILITY NUMBER: 015600693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia:

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


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 by not locking kitchen knifes that were located in the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2022
Plan of Correction
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Licensee agreed to lock up all knifes in a locked drawer and to submit a photo to CCL by POC due date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022


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Document Has Been Signed on 12/30/2022 01:09 PM - It Cannot Be Edited


Created By: Liridon Fici On 12/30/2022 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PLEASANT HILL MANOR
FACILITY NUMBER: 015600693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 by making sure all appliances are repaired and are in good condition, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2023
Plan of Correction
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Licensee agreed to repair or replace the fridge in the garage and to submit a photo to CCL by POC due date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 by blocking the back yard gate and blocking the stairs going up stairs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2023
Plan of Correction
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Agreed to remove all blocked passesages and to ensure that all pathways are not block for the safety of resident and to submit a photo to CCL by POC due date.

Deficiency Cleared
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/30/2022 01:09 PM - It Cannot Be Edited


Created By: Liridon Fici On 12/30/2022 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PLEASANT HILL MANOR
FACILITY NUMBER: 015600693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 by not keeping enough food supply in the refrigerator, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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Licensee agreed to purchase more food to be stored in the refrigerator and to submit a photo of stocked food to CCL by POC due date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022


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