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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200794
Report Date: 04/26/2024
Date Signed: 04/26/2024 11:53:18 AM

Document Has Been Signed on 04/26/2024 11:53 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TICE VALLEY RESIDENTIAL CAREFACILITY NUMBER:
079200794
ADMINISTRATOR/
DIRECTOR:		SANTIAGO, RACHELLE HFACILITY TYPE:
740
ADDRESS:2206 TICE VALLEY BLVDTELEPHONE:
(925) 705-7841
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 6DATE:
04/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Licensee Mark GutierrezTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 4/26/2024 at 8:45 AM, Licensing Program Analysts (LPAs) J. Sampair and A. Gharachorloo arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPAs stated the purpose of the visit to Caregivers Carlo Castro and Butch Cortez. Licensee Mark Gutierrez arrived at approximately 9:45 AM.

LPAs inspected the interior and exterior of the facility, including 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 dining room was measured at 70.4 degrees Fahrenheit at 11:44 AM. Fire extinguisher was fully charged and last replaced on 7/2/2023.

The carbon monoxide and smoke detector were fully operational. The LPAs 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.

An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPAs reviewed facility records, records of 3 staff members, and records of 5 residents. The LPAs interviewed 2 staff members and 1 resident.

1 Type-B citation issued (refer to LIC809D).

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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 04/26/2024 11:53 AM - It Cannot Be Edited


Created By: James Sampair On 04/26/2024 at 11:31 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: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for 3 of 5 residents missing the form LIC 602 and/or other pre-placement physical and psychological assessments, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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On or before due date, Licensee shall send proof to LPA that an appointment has been scheduled for the residents to have their pre-placement medical assessments and/or to add missing documentation including Consent Forms, Admission Agreements, and Statement of Valuables.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
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