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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201362
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:33:25 PM

Document Has Been Signed on 07/23/2024 02:33 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:CAMELLIA GARDEN CARE VILLAFACILITY NUMBER:
079201362
ADMINISTRATOR/
DIRECTOR:
MANALANG-ENRIQUEZ, JOYFACILITY TYPE:
740
ADDRESS:2832 MI ELANA CIRCLETELEPHONE:
(925) 945-1237
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
07/23/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Licensee Joy Manalang-EnriquezTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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On 7/23/2024 at 12:45 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the Post Licensing Inspection. Upon entry, LPA stated the purpose of the visit to Licensee Joy Manalang-Enriquez.

The LPA inspected the interior and exterior of the facility. The inspection of the physical plant included 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 76.4 degrees Fahrenheit at 1:33 PM. The fire extinguisher was fully charged and last replaced 3/13/2024.



The carbon monoxide and smoke detectors were fully operational. The LPA observed required postings in the facility, including the Residential Care Facility for the Elderly Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

The LPA reviewed facility records, records of 5 residents, and records of 5 staff members. The LPA interviewed 2 staff members and 2 residents.

One Type-A citation (refer to LIC 809-D) were issued during the inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 07/23/2024 02:33 PM - It Cannot Be Edited


Created By: James Sampair On 07/23/2024 at 02:25 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: CAMELLIA GARDEN CARE VILLA

FACILITY NUMBER: 079201362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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 1 location, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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