<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601562
Report Date: 03/24/2023
Date Signed: 03/24/2023 03:46:28 PM

Document Has Been Signed on 03/24/2023 03:46 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:CORTE VISTA GUEST HOMEFACILITY NUMBER:
075601562
ADMINISTRATOR:BRYSON WRIGHTFACILITY TYPE:
740
ADDRESS:1724 CORTE VISTA STREETTELEPHONE:
(925) 586-6598
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Jane Rotich, caregiver TIME COMPLETED:
04:00 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 this day 03/24/2023 at around 2:05PM, Licensing Program Analyst (LPA) L. Ibo arrived at the facility to conduct annual required inspection. LPA was met by caregiver Jane Roytich, LPA informed her the purpose of the visit. LPA called Administrator Bryson Wright, according to Administrator he was not available to meet with LPA.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, garage dining and living areas. Facility has an approved fire clearance for 6 non ambulatory residents. One fire extinguisher was observed by the kitchen area, however there was no service date tag available for review.

Facility has sufficient supply of perishable and non-perishable foods. Bathrooms were observed with grab bars and nonskid mats.

LPA observed the following:
At 2:51PM, Administrator admitted that facility do not have liability insurance.
At 2:53PM, LPA observed that carbon monoxide at the hallway was not functional.
Staff cannot provide her staff file for LPA to review.

LPA will continue annual inspection; Administrator was not available during the visit and there was information that caregiver on duty cannot provide to LPA. Interviews will follow.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.


Exit interview was conducted with care staff and Appeal Rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023
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 2
Document Has Been Signed on 03/24/2023 03:46 PM - It Cannot Be Edited


Created By: Leslie Ibo On 03/24/2023 at 03:27 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: CORTE VISTA GUEST HOME
FACILITY NUMBER: 075601562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review)], the licensee did not comply with the section cited above in licensee failed to obtain liability insurance for the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
1
2
3
4
Adminsitrator stated he will obtain liability insurance as soon as possible. LPA need copy of the insurance by POC date.
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 licensee failed to have a functional carbon monoxide detector which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2023
Plan of Correction
1
2
3
4
Administrator will purchase a new carbon monoxide detector for the facility, a proof or purchase will need to be submitted to LPA by POC 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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2