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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200613
Report Date: 08/19/2022
Date Signed: 08/19/2022 11:02:14 AM

Document Has Been Signed on 08/19/2022 11:02 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:LAS JUNTAS HOMEFACILITY NUMBER:
079200613
ADMINISTRATOR:YAMSUN, BANAAG FFACILITY TYPE:
740
ADDRESS:121 LAS JUNTAS WAYTELEPHONE:
(925) 954-8839
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 4CENSUS: 4DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Paul Rivera, LeadTIME COMPLETED:
11:10 AM
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 8/19/2022 at 09:30AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Lead, Paul Rivera explained the purpose of the visit. LPA spoke with Administrator, Banaag Yamsun, and was given approval for Lead to sign documents.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared residents' bathroom was measured at 97.6 degrees Fahrenheit. Fire extinguisher last serviced on 10/1/2021. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed temperature and sign-in log for visitors. LPA observed facility has a copy of Infection Control Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

Continued on LIC809C.



SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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
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: LAS JUNTAS HOME
FACILITY NUMBER: 079200613
VISIT DATE: 08/19/2022
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
26
27
28
29
30
31
32
Continued from LIC809.

LPA request the following documents to be submitted to CCLD by 8/26/2022.
  • Copy of Administrator certificate.
  • LIC500 Personnel Report
  • LIC308 Designation of Administrative Responsibility
  • LIC610E Emergency Disaster Plan

The following deficiency was observed:

-At 10:00AM, LPA observed 2 chairs, a wheelchair, plywood, a shelf, wood pieces and a box on right side of house blocking passageway.

The following deficiency was observed (see LIC809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 08/19/2022 11:02 AM - It Cannot Be Edited


Created By: Laura Hall On 08/19/2022 at 10:39 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: LAS JUNTAS HOME
FACILITY NUMBER: 079200613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accomendations and Services
(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor pasaageways and stairways should be kept free of obstruction.
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 having an outdoor passageway free of obstruction which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
1
2
3
4
Administrator agreed to remove all items on right side of house to make passageway free of any obstructions and submit a photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4