Community Care Licensing

Type A

Section Cited

CCR

87307(d)(6)

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed padlock installed on sliding door. Based on record review, sliding door is noted as an emergency exit which poses an immediate health, safety risk to persons in care.
	POC Due Date: 08/26/2021
	Plan of Correction
1 2 3 4	DEFICIENCY CLEARED LPAs observed staff removed locked from the sliding door. A CIVIL PENALTY OF $500 IS BEING ASSESSED

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed bathrooms were not clean and sanitary, and ramp is in disrepair which poses potential health and safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2021
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to deep clean the bathrooms and repair the ramp and send a photo to CCL.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021

Type B

Section Cited

HSC

1569.17(b)(1)(C)

(C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene. Any nurse assistant or home health aide meeting the requirements of Section 1338.5 or 1736.6, respectively, who is not employed, retained, or contracted by the licensee, and who has been certified or recertified on or after July 1, 1998, shall be deemed to meet the criminal record clearance requirements of this section. A certified nurse assistant and certified home health aide who will be providing client assistance and who falls under this exemption shall provide one copy of his or her current certification, prior to providing care, to the residential care facility for the elderly. The facility shall maintain the copy of the certification on file as long as the care is being provided by the certified nurse assistant or certified home health aide at the facility. Nothing in this paragraph restricts the right of the department to exclude a certified nurse assistant or certified home health aide from a licensed residential care facility for the elderly pursuant to Section 1569.58. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPAs observed S1 does not complete ADL training on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2021
	Plan of Correction
1 2 3 4	By POC date, Adminsitrator agrees to complete training for S1 and submit a self-certification to CCL.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021

Type B

Section Cited

HSC

1569.69(a)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Based on record review, LPAs observed S1 does not have complete medication trainin on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2021
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to complete medication training for S1 and submit a self-certification to CCL.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021

Type B

Section Cited

CCR

87303(3)(D)

87303 Personal Accomodations (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above. LPAs observed bathrooms were not equipped with toilet paper, handsoap and paper towel which poses a personal rights concern to residents in care.
	POC Due Date: 08/27/2021
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to replenish bathrooms with handsoap, toilet paper and paper towel and submit a self certification letter to CCL

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021