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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601574
Report Date: 08/25/2022
Date Signed: 08/25/2022 05:07:50 PM

Document Has Been Signed on 08/25/2022 05:07 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:SANS SOUCIFACILITY NUMBER:
075601574
ADMINISTRATOR:JENETTE COPEFACILITY TYPE:
740
ADDRESS:330 EL DIVISADERO AVENUETELEPHONE:
(925) 949-8475
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nemesio "Jun" Lopez and Katherine GrutasTIME COMPLETED:
06:00 PM
NARRATIVE
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On 8/25/22 at 10:30 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit. Staff member Nemesio "Jun" Lopez and Administrator Katherine Grutas toured the facility inside and outside with LPA.

Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing.

The temperature inside of the facility was 78.8 and the hot water was 110 degrees Fahrenheit, both of which were in the safe range. Fire extinguisher was fully charged and had been updated within the past year. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

Facility cited for 1 Type A and 3 Type B deficiencies (refer to LIC 809-D).

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/01/22:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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 08/25/2022 05:07 PM - It Cannot Be Edited


Created By: James Sampair On 08/25/2022 at 03:47 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: SANS SOUCI
FACILITY NUMBER: 075601574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 the hall closet and under the sink cabinets that were accessible to residents that contained Febreze and cleaning products were unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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During visit, staff removed the dangerous products from the storage areas.
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: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/25/2022 05:07 PM - It Cannot Be Edited


Created By: James Sampair On 08/25/2022 at 03:47 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: SANS SOUCI
FACILITY NUMBER: 075601574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, the licensee did not comply with the section cited above with a non-operable carbon monoxide detector, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Licensee shall replace with operating carbon monoxide detector and send proof to LPA before due date.
Type B
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services
(5) The licensee shall assist residents with self-administered medications as needed.

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 because staff members assisting residents in the administration of their medications are not completing the Medication Administration Record (MAR) LIC 622A form nor any other recording of the administration of residents' medications, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Licensee will send proof to LPA that the Plan of Operation has been updated to include the recording of medication administration and that staff are using the LIC 622A by the 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: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/25/2022 05:07 PM - It Cannot Be Edited


Created By: James Sampair On 08/25/2022 at 03:47 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: SANS SOUCI
FACILITY NUMBER: 075601574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 when Administrator transfers medications from original container into a different container for staff to administer medications at a later date and time, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Licensee will send proof to LPA by the due date that: (1) staff administer medications directly from the original container and that the administration of that medication is being recorded in the Medication Administration Record (MAR) LIC 622A and (2) in accordance with Health and Safety Code section 1569.69 as referenced in TSP 2016-03 (version 08/30/2021), the Plan of Operation has been updated to require training of staff to administer medications.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
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