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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201061
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:19:04 PM

Document Has Been Signed on 09/15/2022 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:CROW CANYON RESIDENTIAL CARE IIIFACILITY NUMBER:
079201061
ADMINISTRATOR:YU, RUFFYFACILITY TYPE:
740
ADDRESS:2254 DOVER WAYTELEPHONE:
(925) 732-2691
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 4DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Loida Tamayo, CaregiverTIME COMPLETED:
04:25 PM
NARRATIVE
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On 9/15/2022 at 3:05PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Loida Tamayo, Caregiver and explained the purpose of the visit. Administrator, Ruffy Yu, arrived at 3:35PM.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs posted near screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 114.0 degrees Fahrenheit. Fire extinguisher last serviced on 12/3/2021. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed facility has a copy of the infection control plan on file. LPA observed food and paper supplies are sufficient.

The following deficiencies were observed:
  • At 3:10PM, LPA observed a pair of scissors drying in sink in dish rack.
  • At 3:25PM, LPA observed gate located on left side of house locked with padlock.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CROW CANYON RESIDENTIAL CARE III
FACILITY NUMBER: 079201061
VISIT DATE: 09/15/2022
NARRATIVE
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Continued from LIC809.

LPA request the following documents to be submitted to CCLD by 9/22/2022.
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Administrator certificate

The following 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 provided and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/15/2022 04:19 PM - It Cannot Be Edited


Created By: Laura Hall On 09/15/2022 at 04:01 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: CROW CANYON RESIDENTIAL CARE III
FACILITY NUMBER: 079201061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a pair of scissors accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Caregiver immediately removed scissors and locked them in a locked kitchen cabinet. Deficiency cleared during visit.
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/15/2022 04:19 PM - It Cannot Be Edited


Created By: Laura Hall On 09/15/2022 at 04:04 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: CROW CANYON RESIDENTIAL CARE III
FACILITY NUMBER: 079201061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(6)
87468.1 Personsal Rights of Residents in all facilities.
(a) Residents in all residential care facilites for the elderly shall have all of the following personal rights:
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having the exterior gate unlocked which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Caregiver immediately removed the padlock from the gate. Deficiency cleared during visit.
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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