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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201044
Report Date: 03/12/2025
Date Signed: 03/12/2025 12:51:29 PM

Document Has Been Signed on 03/12/2025 12:51 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:DEER RIDGE COUNTRY VILLAFACILITY NUMBER:
079201044
ADMINISTRATOR/
DIRECTOR:		SALAZAR, HENRYFACILITY TYPE:
740
ADDRESS:419 DEL MONTE COURTTELEPHONE:
(925) 997-7354
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
03/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Kimberly Whittle, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 03/12/2025 at 10:30AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a case management visit regarding the incident reports received on 03/11/2025. LPA met with Administrator, Kimberly Whittle and explained the purpose of visit.

Based on the incident reports dated 03/06/2025 and 03/10/2025 revealed that resident (R1) had unwitnessed falls. R1 falls were caught on the camera in R1's bedroom supplied and used by R1’s family. On 03/03/2025, at approximately 10:00pm R1 fell after losing balance while getting items from dresser. On 03/10/2025, at approximately 3:00am, R1 had gotten up, R1's alarm pad had not sounded to notify a caregiver that R1 was up and in need of assistance and when R1 tried to put robe on and fell.

During visit, LPA toured R1’s room, interviewed administrator and reviewed R1’s file. During the visit, LPA observed Camera with audio and video recording capabilities located in R1’s room. During interview, administrator stated camera was provided and installed by family. During file review LPA observed R1’s physician’s report didn’t indicate fall risk. Staff removed the camera during visit.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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 03/12/2025 12:51 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/12/2025 at 12:27 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: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
87468.2(a)

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87468.2 (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all the following personal rights: This requirement was not met as evidence by:
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Staff immediately removed the camera with audio and recording capabilities during visit. Deficiency cleared.
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Based on observation, the licensee did not comply with the section cited above by having a camera with audio and recording capabilities in R1's room which poses a potential 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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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