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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601035
Report Date: 02/22/2023
Date Signed: 02/23/2023 07:37:38 AM

Document Has Been Signed on 02/23/2023 07:37 AM - 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:CARRIAGE CAREFACILITY NUMBER:
075601035
ADMINISTRATOR:TUAZON, GABRIEL & ERLINDAFACILITY TYPE:
740
ADDRESS:1959 CARRIAGE DRIVETELEPHONE:
(925) 977-9678
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 3DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Gabriel and Erlinda TuazonTIME COMPLETED:
04:45 PM
NARRATIVE
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On 02/22/2023 at 1:55 PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry into facility, LPA explained the purpose of the visit. LPA met with and toured the facility with Licensee ERLINDA TUAZON.

Facility has a Covid-19 Mitigation Plan and an Infection Control Plan. They were cited for not following aspects of COVID-19 Infection Control.

Carbon monoxide and smoke detectors were fully functional and the fire extinguisher had been serviced within one (1) year and it was fully charged. Centrally stored medications were in locked cabinets, and sharp objects were stored in locked closets and cabinets. The temperature inside of the facility was 78 and the hot water was 118 degrees Fahrenheit, both of which were in the safe range. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

Facility cited with 1 A and 1 Type B deficiencies and 1 civil penalty (refer to LIC 809D and LIC 421FC).

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 03/01/2023:
  • · LIC500 - Personnel Report
  • · LIC308 - Designation of Facility Responsibility
  • · LIC610E - Emergency/Disaster Plan
  • · Evidence of adequate Liability Insurance

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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 02/23/2023 07:37 AM - It Cannot Be Edited


Created By: James Sampair On 02/22/2023 at 03:38 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: CARRIAGE CARE
FACILITY NUMBER: 075601035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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 2 aspects: caregiver unmasked and no signage posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/23/2023 07:37 AM - It Cannot Be Edited


Created By: James Sampair On 02/22/2023 at 03:38 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: CARRIAGE CARE
FACILITY NUMBER: 075601035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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3
4
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

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 3 out of 3 gates, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Add self-closing mechanisms to every gate. Inform LPA of the repairs on or before due date.
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 Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3