Community Care Licensing

Document Has Been Signed on 11/21/2023 04:50 PM - It Cannot Be Edited

FACILITY NAME:	TICE VALLEY RESIDENTIAL CARE		FACILITY NUMBER:	079200794
ADMINISTRATOR:	SANTIAGO, RACHELLE H		FACILITY TYPE:	740
ADDRESS:	2206 TICE VALLEY BLVD		TELEPHONE:	(925) 705-7841
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94595
CAPACITY: 6		CENSUS: 5	DATE:	11/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Rachelle Perez		TIME COMPLETED:	05:00 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023

Link to Parent Document Below:

FACILITY NAME: TICE VALLEY RESIDENTIAL CARE	FACILITY NUMBER: 079200794
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 2 out of 6 employees, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	All current employees must have completed Health Report with TB testing on or before due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023

Link to Parent Document Below:

FACILITY NAME: TICE VALLEY RESIDENTIAL CARE	FACILITY NUMBER: 079200794
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

Type B

Section Cited

HSC

1569.618(c)(3)

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 5 out of 5 staff people do not have CPR training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	All current employees must have completed CPR training on or before due date.

Type B

Section Cited

CCR

87465(a)(8)(A)

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. 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 1 out of 1 first aid kits, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	Licensee shall obtain a complete first aid kit for the facility on or before the due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023

Link to Parent Document Below:

FACILITY NAME: TICE VALLEY RESIDENTIAL CARE	FACILITY NUMBER: 079200794
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

Type B

Section Cited

CCR

87618(b)(3)

(3) Ensuring that the use of oxygen equipment meets the following requirements: 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 1 out of 1 residents using oxygen equipment, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	Licensee shall post signs and submit a written report to local fire jurisdiction that oxygen is in use at the facility.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023