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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600912
Report Date: 08/04/2021
Date Signed: 08/04/2021 05:28:51 PM

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:MURIEL'S RESIDENTIAL FACILITY IIFACILITY NUMBER:
015600912
ADMINISTRATOR:IRENE M. JENKINSFACILITY TYPE:
740
ADDRESS:4643 HAMPSHIRE WAYTELEPHONE:
(510) 703-8248
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 6DATE:
08/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Noel Morales, Staff
Irene Jenkins, Licensee		TIME COMPLETED:
05:40 PM
NARRATIVE
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On 8/4/2021 at 1:45PM, Licensing Program Analysts (LPAs) G. Luk and J. Sampair arrived unannounced to conduct an Infection Control Inspection. LPAs met with staff, Noel Morales and explained the purpose of the visit. LPAs spoke with licensee, Irene Jenkins over the phone and obtain information for inspection control inspection. Licensee was unable to be at the facility.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, and outdoor areas. LPAs observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log and temperature logs for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPEs, food, and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 2:00PM, LPAs observed unlocked knives, cleaning supplies, paints, and tools. Staff locked up all items during inspection.
-At 2:10PM, LPAs observed unlocked medications in the kitchen. Staff locked up medication.
-At 2:12PM, LPAs observed staff is preparing medications a week in advance.
-At 2:15PM, LPAs observed resident had a full bed rail and not on hospice care. Staff removed full bed rail and replaced it with a half bed rail for resident.
-At 2:30PM, LPAs observed side gate was in disrepair.
-At 2:40PM, LPAs observed staff room was changed into 2 small staff room.
-At 3:00PM, LPAs observed that staff did not document residents' changes in condition.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies may result in Civil Penalties.
Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
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 8
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: MURIEL'S RESIDENTIAL FACILITY II
FACILITY NUMBER: 015600912
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021

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 by having unlocked knives, cleaning supplies, paints, and tools which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Staff removed and lock up the knives, cleaning supplies, paints, and tools during inspection.

Deficiency cleared during inspection.
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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4
Based on observation, the licensee did not comply with the section cited above by having unlocked medications which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Staff lock up medications during inspection.

Deficiency cleared during inspection.
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: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 8
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: MURIEL'S RESIDENTIAL FACILITY II
FACILITY NUMBER: 015600912
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 full bed rails for resident who is not receiving hospice care which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Staff removed full bed rails and replaced it with half bed rails during inspection.

Deficiency cleared during inspection.
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: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: MURIEL'S RESIDENTIAL FACILITY II
FACILITY NUMBER: 015600912
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not documenting resident's changes in condition which poses a potential health and safety risk to persons in care.
POC Due Date: 08/25/2021
Plan of Correction
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Administrator has agreed to conduct training for staff regarding documenting resident's changes in condition and provide staff sign-in sheet to CCLD by POC date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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Based on observation, the licensee did not comply with the section cited above by having side gate in disrepair which poses a potential health and safety to persons in care.
POC Due Date: 08/25/2021
Plan of Correction
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Administrator will provide picture/video proof that side gate is repaired and in operating condition. Administrator will submit picture 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 4 of 8
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: MURIEL'S RESIDENTIAL FACILITY II
FACILITY NUMBER: 015600912
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

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 alterations to a staff room which poses a potential health and safety risk to persons in care.
POC Due Date: 08/25/2021
Plan of Correction
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Administrator had agreed to provide a new sketch to CCLD by POC date. Administrator will provide documentation of permits to CCLD by POC date.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 medications prepared a week in advance which poses a potential health and safety risk to persons in care.
POC Due Date: 08/25/2021
Plan of Correction
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Administrator has agreed to conduct training to all staff regarding preparing medications and submit staff sign-in sheet 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 5 of 8