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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200794
Report Date: 02/15/2023
Date Signed: 02/15/2023 10:49:00 AM

Document Has Been Signed on 02/15/2023 10:49 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:TICE VALLEY RESIDENTIAL CAREFACILITY NUMBER:
079200794
ADMINISTRATOR:SANTIAGO, RACHELLE HFACILITY TYPE:
740
ADDRESS:2206 TICE VALLEY BLVDTELEPHONE:
(925) 705-7841
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 5DATE:
02/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:MARK GUTIERREZTIME COMPLETED:
10:55 AM
NARRATIVE
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During a health check visit on 02/15/2023, Licensing Program Analyst (LPA) James Sampair observed a deficiency concerning care for persons with dementia. During the LPA's inspection of the exterior of the building, it was observed that one of the 3 gates were not self-closing, for details refer to LIC 809D.

One citation was issued during inspection.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/15/2023 10:49 AM - It Cannot Be Edited


Created By: James Sampair On 02/15/2023 at 10:36 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: TICE VALLEY RESIDENTIAL CARE
FACILITY NUMBER: 079200794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2023
Section Cited
CCR
87705(h)

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87705 Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
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On or before due date, Licensee shall add self-closing mechanism to the gate without one.
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Based on observation, the licensee did not comply with the section cited above in 1 out of 3 gates that was not self-closing, which poses a potential health, safety or personal rights 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: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023


LIC809 (FAS) - (06/04)
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