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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200794
Report Date: 09/30/2022
Date Signed: 09/30/2022 04:19:20 PM

Document Has Been Signed on 09/30/2022 04:19 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:TICE VALLEY RESIDENTIAL CAREFACILITY NUMBER:
079200794
ADMINISTRATOR:SANTIAGO, RACHELLE HFACILITY TYPE:
740
ADDRESS:2206 TICE VALLEY BLVDTELEPHONE:
(925) 658-8942
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 5DATE:
09/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rachelle SantiagoTIME COMPLETED:
04:45 PM
NARRATIVE
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On 09/30/2022, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced Plan of Correction (POC) inspection of the facility to verify that the POC corrections had been implemented in a manner consistent with POC dated 09/19/2022. Upon entry into the facility, the LPA identified himself and the purpose of the visit to staff members who immediately called Administrator Rachelle Santiago to come to the facility.

The Administrator arrived after the LPA had completed his inspection of the facility inside and out. During his inspection, the LPA was able to verify that 1 of the 3 POCs were able to be cleared. The facility was fined for not clearing the other 2 by the due date a total of $1,500. Additionally, the facility was cited for 2 more deficiencies (refer to LIC 809-D).

A total of 2 civil penalties and 4 deficiencies (1 Type-A and 3 Type-B) were issued during the visit. A copy of this report was provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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 3
Document Has Been Signed on 09/30/2022 04:19 PM - It Cannot Be Edited


Created By: James Sampair On 09/30/2022 at 01:37 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: TICE VALLEY RESIDENTIAL CARE
FACILITY NUMBER: 079200794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2022
Section Cited
CCR
87705(j)

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87705 CARE OF PERSONS WITH DEMENTIA (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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Administrator agreed to install an auditory device and to provide picture proof to the LPA by the due date.
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Based on observation by the LPA, the Licensee did not comply with the section cited above. No auditory device is on 1 out of 7 of the facility exits, which poses a potential health and safety risk to persons in care.
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Type B
10/07/2022
Section Cited
CCR87405(a)

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87405 ADMINISTRATOR - QUALIFICATIONS AND DUTIES (a) All facilities shall have a qualified... administrator . . . The administrator... shall be on the premises a sufficient number of hours.... The Department may require that the administrator devote additional hours in the facility... This requirement was not met as evidence by:
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Administrator agreed to: (1) update LIC500 to reflect days and hours she will be present as Administrator at the facility. (2) Review Title 22 regulation 87405 "Administrator – Qualifications and Duties".
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Based on observation by the LPA, the Licensee did not comply with the section cited above. An Administrator has not been on premises a sufficient number of hours (20 per week minimum), which poses a potential health and safety risk to persons in care.
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(3) Submit a self-certification that the regulation has been reviewed and administrator will abide by the regulation going forward. (4) Self-certification and updated LIC500 will be submitted by the 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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2022 04:19 PM - It Cannot Be Edited


Created By: James Sampair On 09/30/2022 at 02:46 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: TICE VALLEY RESIDENTIAL CARE
FACILITY NUMBER: 079200794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2022
Section Cited
CCR
87303(e)(2)

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87303 MAINTENANCE AND OPERATION (e) Water supplies . . . shall be maintained as follows: (2) Faucets used by residents . . . hot water . . . attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
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Administrator agreed to: (1) Self-certify that the hot water temperature was between 105 and 120 degrees F. (2) Purchase a thermometer to accurately measure water temperature. (3) Create and train staff in updating a daily hot water temperature log going forward.
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Based on observation by the LPA, the Licensee did not comply with the section cited above. The hot water temperature was measured at 130 degrees, which poses an immediate health and safety risk to persons in care.
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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: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022


LIC809 (FAS) - (06/04)
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