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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200781
Report Date: 05/13/2024
Date Signed: 05/13/2024 05:56:40 PM

Document Has Been Signed on 05/13/2024 05:56 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NEW HAVENFACILITY NUMBER:
079200781
ADMINISTRATOR/
DIRECTOR:		ELIZABETH CORTES- PALADFACILITY TYPE:
740
ADDRESS:2236 WHYTE PARK AVENUETELEPHONE:
(510) 965-5555
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 6DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Lead Staff Marilou LadabanTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 05/13/2024 at 1:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPA disclosed the purpose of the visit with Lead Staff Marilou Ladaban.

The LPA inspected the interior and exterior of the facility that included the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the living room was measured at 71.4 degrees Fahrenheit at 3:28 PM. The LPA observed postings in the facility that included a complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council, and Rights to Family Council. The carbon monoxide and smoke detector were tested and found to be fully operational. 3 fire extinguishers were fully charged, but the facility was cited because they had not been serviced since 9/8/2022. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

The LPA reviewed records of 5 residents. The LPA interviewed 2 staff members and 2 residents.

During the inspection, 2 B-Type citations were issued (refer to LIC809-D for details).

Annual inspection incomplete. LPA will return unannounced at a future date and time to complete the inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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 3
Document Has Been Signed on 05/13/2024 05:56 PM - It Cannot Be Edited


Created By: James Sampair On 05/13/2024 at 05:21 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: NEW HAVEN
FACILITY NUMBER: 079200781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire
Marshal for the protection of life and property against fire and panic.

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 3 out of 3 fire extinguishers, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2024
Plan of Correction
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On or before due date, Licensee shall send proof to LPA of the purchase of new or the service of existing fire extinguishers and that they have scheduled the service of or replacement of existing fire extinguishers on an annual basis.
Section Cited
Deficient Practice Statement
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4
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: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/13/2024 05:56 PM - It Cannot Be Edited


Created By: James Sampair On 05/13/2024 at 05:28 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: NEW HAVEN
FACILITY NUMBER: 079200781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2024

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
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4
Based on record review, the licensee did not comply with the section cited above in 4 of 4 quarters and every shift, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2024
Plan of Correction
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On or before due date, Licensee shall conduct emergency/disater drill for every shift and send proof to LPA.
Section Cited
Deficient Practice Statement
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3
4
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: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024


LIC809 (FAS) - (06/04)
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