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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600386
Report Date: 10/27/2021
Date Signed: 10/27/2021 05:43:48 PM

Document Has Been Signed on 10/27/2021 05:43 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:HARTNELL HOME CAREFACILITY NUMBER:
015600386
ADMINISTRATOR:PURUGANAN,VICTORIA C.FACILITY TYPE:
740
ADDRESS:2041 HARTNELL STREETTELEPHONE:
(510) 489-7290
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Erlinda Kloulubak, Lead CaregiverTIME COMPLETED:
05:55 PM
NARRATIVE
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On 10/27/2021 starting at 1:33pm, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct Infection Control Inspection. LPA met with the Caregiver Erlinda Kloulubak and explained the purpose of the visit. Administrator Victoria Puruganan was unable to come to the facility due to family issue, and authorized Erlinda to assist with the inspection.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Mitigation Plan, Emergency Disaster Plan and maintains record of routine screening for residents, staff and visitors.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· At 1:50PM, LPA observed unlocked centrally stored medications cabinet. Staff locked up the medication cabinet during inspection.
· At 1:52PM, LPA observed unlocked knives in a kitchen drawer. Staff locked up the knives to somewhere else during inspection.
· At 1:55PM, LPA observed unlocked cleaning supplies including bleach, all purposes orange and Raid in a kitchen cabinet. Staff locked up the cabinet during inspection.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

LPA spoke with Administrator who gave permission to staff sign and receive report. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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 10/27/2021 05:43 PM - It Cannot Be Edited


Created By: Catherine Lin On 10/27/2021 at 04:35 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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by:

87465(h)(2) - (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.
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above. LPAs observed medications in kitchen cabinet was unlocked which poses an immediate health, safety risk to persons in care.
POC Due Date: 10/28/2021
Plan of Correction
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Deficiency cleared during visit. LPA observed staff locked up medication cabinet. In addition, Administrator will retrain staff on regulation and submit a copy of training agenda to CCLD by POC date.
Type A
Section Cited
CCR
87705(f)(1)


This requirement is not met as evidenced by:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unlocked knives and cleaning supplies in the kitchen drawer and cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2021
Plan of Correction
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1. LPA observed staff moved all knifvies to a locked cabinet during visit. Administrator agreed to install a lock to the knife cabinet and submit photos to CCLD by POC date.
2. LPA observed staff locked up the cleaning supplies cabinet during visit. Deficiency cleared. In addition, Administrator will retrain staff on regulation and submit a copy of training agenda to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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