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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601187
Report Date: 03/07/2025
Date Signed: 03/07/2025 05:40:42 PM

Document Has Been Signed on 03/07/2025 05:40 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:HRS CARE HOMEFACILITY NUMBER:
015601187
ADMINISTRATOR/
DIRECTOR:		DE LUNA, DIOSDADOFACILITY TYPE:
740
ADDRESS:1352 ASTER LANETELEPHONE:
(925) 454-3320
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 4DATE:
03/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Eillen Catilo, Caregiver/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:55 PM
NARRATIVE
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On 3/7/2025 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver/administrator, Eillen Catilo and explained the purpose of the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 1/3/2025. One week of nonperishable and 2-day of perishable food supplies were available. Hot water was measured at 105.3 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. First Aid kit is complete. Last fire and earthquake drill was conducted on 1/2/2025. LPA reviewed 4 residents and 4 staff files starting at 12:45PM. LPA reviewed a sample of resident's medications during inspection.

At 11:40AM, LPA observed unlocked paints, fertilizer, and gardening tools in the backyard. Staff locked up the items during inspection. Civil penalty of $250 is being assessed for a repeat violation.
At 1:00PM, LPA observed resident's files were incomplete and missing signed admission agreement, preplacement appraisals, personal rights, and current reappraisals.
At 3:45PM, LPA observed R3 did not have a PRN medication (Lactulose Solution) available. Administrator stated R3 have not taken the PRN medication in a while and R3 have other medications in place of it. Facility is preparing resident's medications a week in advance.

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

Exit interview conducted with Eillen Catilo. A copy of this report, civil penalties, and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
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 03/07/2025 05:40 PM - It Cannot Be Edited


Created By: Grace Luk On 03/07/2025 at 04:25 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: HRS CARE HOME
FACILITY NUMBER: 015601187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 paints, fertilizer, and gardening tools in the backyard which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/08/2025
Plan of Correction
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Staff locked up the items during inspection.
Civil penalty of $250 is being assessed for a repeat violation.

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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/07/2025 05:40 PM - It Cannot Be Edited


Created By: Grace Luk On 03/07/2025 at 05:02 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: HRS CARE HOME
FACILITY NUMBER: 015601187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(d)
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

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 having incomplete resident files which poses a potential health and safety risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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Administrator has agreed to obtained signed documents for all residents for future reviews. Administrator will submit self-certification to CCLD by POC date.
Type B
Section Cited
CCR
87465(a)(4)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having PRN medications available and preparing medications a week in advance which poses a potential health and safety risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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Administrator has agreed to obtain R3's PRN medication or a discontinue order for Lactulose Solution. Administrator has agreed to conduct training regarding preparing medications and obtaining PRN medications. Administrator will submit picture proof or discontinue order and 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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
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