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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601406
Report Date: 08/13/2021
Date Signed: 08/13/2021 11:28:31 AM

Document Has Been Signed on 08/13/2021 11:28 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:LA CASA VERDEFACILITY NUMBER:
075601406
ADMINISTRATOR:ALCANTARA, LEONARDOFACILITY TYPE:
740
ADDRESS:1405 CAMINO VERDETELEPHONE:
(925) 285-5078
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 6CENSUS: 0DATE:
08/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Leonardo Alcantara, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) L. Francisco conducted a case management visit and met with the Administrator. LPA explained to the Administrator purpose of the visit.

During the investigation process conducted by the Department, S1 states R1 was falling on a regular basis. S1 did not obtain medical attention for R1, even though one fall resulted in a significant cut to the back of R1’s head. Another fall resulted in the mirror on a closet door shattering. S1 was unable to provide an explanation for how the falls occurred. S1 stated R1’s family is responsible in taking R1 to the doctor. S1 stated had not seen a doctor since January 31, 2019 because the family was not taking R1. Kaiser Walnut Creek medical records did not show any visits or calls regarding increased falls or injuries until R1’s brother called on 3/8/2021 to request an appointment to have R1 evaluated.

During interview conducted by LPA Luisa Fontanilla on 5/19/2021, Administrator and S1 confirmed that no incident reports were submitted to CCL for the fall incidents.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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 08/13/2021 11:28 AM - It Cannot Be Edited


Created By: Lizette Francisco On 08/13/2021 at 10:48 AM
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: LA CASA VERDE
FACILITY NUMBER: 075601406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2021
Section Cited
CCR
87465(a)(1)

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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. ........... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
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By POC date, Administrator states Sec 87465 will be reviewed with the staff and submit self-certification indicating completion of training.
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Based on interviews and record reviews, facility failed to assist R1 in arranging for medical care appropriate to R1's needs and condition. S1 states R1 has not seen R1's doctor since 1/31/2019 because the family was not taking R1. And that taking R1 to the doctor is not S1's responsibility. This poses an immediate health risk to the clients under care.
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Type B
08/27/2021
Section Cited
CCR87211(a)(1)(D)

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a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence… (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident
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By POC date, Administrator states that he will review Sec 87211 and submit self-certification
stating understanding of Reporting Requirements
by POC date.
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This requirement is not met as evidenced by: On 5/19/2021, Administrator confirmed with LPA that no incident reports were submitted to CCL for the fall incidents which poses a potential risk to health and safety of clients under care.
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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 Humpal
LICENSING EVALUATOR NAME:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021


LIC809 (FAS) - (06/04)
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