<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079200613
Report Date:
09/04/2024
Date Signed:
09/04/2024 04:56:55 PM
Document Has Been Signed on
09/04/2024 04:56 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
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
LAS JUNTAS HOME
FACILITY NUMBER:
079200613
ADMINISTRATOR/
DIRECTOR:
YAMSUN, BANAAG F
FACILITY TYPE:
740
ADDRESS:
121 LAS JUNTAS WAY
TELEPHONE:
(925) 954-8839
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94597
CAPACITY:
4
CENSUS:
4
DATE:
09/04/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:
Banaag Yamsun, Administrator
TIME VISIT/
INSPECTION COMPLETED:
05:10 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 09/04/2024 at 11:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Banaag Yamsun and explained the purpose of the visit. The facility’s fire clearance was approved for four (4) Non-ambulatory. Hospice waiver for two (2) residents. Administrator certificate # 6019296740 expires 07/01/2025.
LPA toured facility with Banaag including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four (4) total bedrooms which 4 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Centrally stored medication and sharps were locked and inaccessible to residents.
Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/22/2024. Emergency Disaster Plan was last posted on 09/04/2024. First aid kit was observed to be complete.
LPA reviewed 4 residents records. LPA reviewed 3 staff records and 2 of 3 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications.
LIC809-C Continued...
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
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
11
Document Has Been Signed on
09/04/2024 04:56 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
09/04/2024
at
03:37 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:
LAS JUNTAS HOME
FACILITY NUMBER:
079200613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observatio, the licensee did not comply with the section cited above in by not having a variety of meats, lunch meats, canned tuna, fruits, vegetables, beans, milk, eggs, breads, snacks, pastas, beans and fresh fruits for four (4) residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/05/2024
Plan of Correction
1
2
3
4
Administrator agree to purchase foods and send a photo or receipt and foods 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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
LIC809
(FAS) - (06/04)
Page:
2
of
11
Document Has Been Signed on
09/04/2024 04:56 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
09/04/2024
at
03:37 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:
LAS JUNTAS HOME
FACILITY NUMBER:
079200613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by having Tide PODS, Lysol Fabric Disinfectant and Lysol Brand New Day All-Purpose Cleaner unlocekd and inaccessible to residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/13/2024
Plan of Correction
1
2
3
4
Administrator agree to conduct a In-Service training and will send a sign participant list of attendance.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having records of trainings for S2-S3, not including all staff of 10 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/02/2024
Plan of Correction
1
2
3
4
Administrator will submit a detailed plan on how they will complete trainings for staff and will submit plan to CCLD 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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
09/04/2024 04:56 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
09/04/2024
at
03:37 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:
LAS JUNTAS HOME
FACILITY NUMBER:
079200613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(1)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility.
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 by not having Personal Rights for RCFE posted which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/02/2024
Plan of Correction
1
2
3
4
Administrator will submit a photo of persoanl rights poster posted 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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
09/04/2024 04:56 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
09/04/2024
at
03:37 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:
LAS JUNTAS HOME
FACILITY NUMBER:
079200613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
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 by not having PUB475 20X26 posted in facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/02/2024
Plan of Correction
1
2
3
4
Administrator will submit a photo of poster posted in facility to CCLD 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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
09/04/2024 04:56 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
09/04/2024
at
03:37 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:
LAS JUNTAS HOME
FACILITY NUMBER:
079200613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
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 by not having record of quarterly fire drills which poses a potential health and safety risk to persons in care.
POC Due Date:
09/05/2024
Plan of Correction
1
2
3
4
Administrator will submit fire drill trainings with participants signatures to CCLD by POC date.
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having updated annual Appriasal Needs and Services (ANS) for R1-R4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/02/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit completed copies of ANS for R1-R4 to CCLD 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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
09/04/2024 04:56 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
09/04/2024
at
03:37 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:
LAS JUNTAS HOME
FACILITY NUMBER:
079200613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in by not having a dr's order for hospital bed for R1 which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/02/2024
Plan of Correction
1
2
3
4
Administrator will submit a copy of dr's order for R1's hospital bed 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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
LIC809
(FAS) - (06/04)
Page:
7
of
11
Document Has Been Signed on
09/04/2024 04:56 PM
- It Cannot Be Edited
Created By:
Lori Alexander-Washington
On
09/04/2024
at
04:23 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:
LAS JUNTAS HOME
FACILITY NUMBER:
079200613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitor
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 by not having mattresses located in outside backyard which poses a potential health, and safety risk to persons in care.
POC Due Date:
09/05/2024
Plan of Correction
1
2
3
4
Administrator will remove the mattress and send 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:
Bennett Fong
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
LIC809
(FAS) - (06/04)
Page:
10
of
11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
LAS JUNTAS HOME
FACILITY NUMBER:
079200613
VISIT DATE:
09/04/2024
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
LIC809-C Continued...
The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/11/2024:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan - Reviewed
Copy of current Liability Insurance
Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
LIC809
(FAS) - (06/04)
Page:
11
of
11