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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600304
Report Date: 07/14/2022
Date Signed: 07/14/2022 11:39:48 AM


Document Has Been Signed on 07/14/2022 11:39 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:QUAIL GARDENFACILITY NUMBER:
015600304
ADMINISTRATOR:PEACOCK, ALICIAFACILITY TYPE:
740
ADDRESS:813 SOUTH J STREETTELEPHONE:
(925) 449-4411
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:20CENSUS: 16DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Alicia Peacock, AdministratorTIME COMPLETED:
11:55 AM
NARRATIVE
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On 7/14/2022 at 9:35AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Alicia Peacock and explained the purpose of the visit.

Upon entry, staff checked LPA's temperature and asked to complete sign-in log. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to residents' bedrooms, bathrooms, kitchen, basement, and common areas. LPA observed physical distancing, signs & symptoms, and mask wearing posted in the common areas. All bathrooms were equipped with soap and paper towel. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. Staff completed FIT testing for N95 respirators and have completion documents. LPA observed PPE, food supplies, and paper supplies are sufficient.

At 9:55AM, LPA observed unlocked medications in the hallway closet where empty medication cups were stored. There were medications in some of those cups. Administrator locked up medications during inspection.

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

Exit interview conducted with Alicia. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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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Document Has Been Signed on 07/14/2022 11:39 AM - It Cannot Be Edited

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: QUAIL GARDEN
FACILITY NUMBER: 015600304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 by having unlocked medication in the hallway closet which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Administrator locked up medications in the medication cups during inspection.

Deficiency cleared.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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