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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201130
Report Date: 04/26/2023
Date Signed: 04/26/2023 11:31:59 AM

Document Has Been Signed on 04/26/2023 11:31 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:PROCARE RETIREMENT HOME,LLCFACILITY NUMBER:
079201130
ADMINISTRATOR:MARYGRACE C ODENAFACILITY TYPE:
740
ADDRESS:208 SAN ANTONIO WAYTELEPHONE:
(925) 378-7896
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
04/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:May MunarTIME COMPLETED:
11:45 AM
NARRATIVE
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At 9:00 AM on 04/26/2023, Licensing Program Analyst (LPA) J Sampair arrived unannounced for a case management visit. Upon entry, LPA explained purpose of the visit to Licensee May Munar.

While conducting the case management visit, the LPA observed 1 Type-B deficiency (refer to LIC809-D for details).

Exit interview conducted. LPA sent copy of this report via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/26/2023 11:31 AM - It Cannot Be Edited


Created By: James Sampair On 04/26/2023 at 10:06 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: PROCARE RETIREMENT HOME,LLC
FACILITY NUMBER: 079201130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2023
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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Licensee shall have a working self-closing mechanism installed at the front gate so that it latches and self-closes.
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Based on observation upon entry at 9:00 AM, the licensee did not comply with the section cited above at 1 of 1 gates that are 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: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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