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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601206
Report Date: 08/03/2021
Date Signed: 08/03/2021 02:04:13 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:CAREFIELD PLEASANTONFACILITY NUMBER:
015601206
ADMINISTRATOR:SINGH, PARVEEN KFACILITY TYPE:
740
ADDRESS:4115 MOHR AVENUETELEPHONE:
(925) 461-8409
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:82CENSUS: 19DATE:
08/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Parveen Singh, Executive DirectorTIME COMPLETED:
02:15 PM
NARRATIVE
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On 8/3/2021 at 1:15PM, Licensing Program Analysts (LPAs) G. Luk and C. Fowler arrived unannounced to conduct a case management inspection due to a change of ownership. LPAs met with Executive Director (ED), Parveen Singh.

During Pre-licensing Inspection, LPAs observed the following deficiencies:

At 10:30AM, LPAs observed hot water temperature on one side of the facility did not meet CCLD regulations. ED explained that the part came in today and installation will be completed tomorrow. In the meantime, residents on that side of the facility had been using the bathrooms from the other side for ADL care.

At 11:30AM, LPAs observed R3 and R4 does not have current medical assessment on file.

At 12:00PM, LPAs observed S4 did not have TB test on file and S3 & S4 did not have health screening on file during record review.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the 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: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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 3
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: CAREFIELD PLEASANTON
FACILITY NUMBER: 015601206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2021
Section Cited

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Maintenance and Operation. Hot water temperature controls shall be maintained...not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidence by:
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Based on observation, licensee did not comply with the section cited above which poses a potential health and safety risk to the persons in care.
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is completed.
Type B
08/20/2021
Section Cited

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Personnel Requirements - General. All personnel...shall be in good health, and...including a chest x-ray...by a physician...
This requirement is not met as evidence by:
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Based on observation, licensee did not comply with the section cited above by not having TB test and health screening for some staff which poses a potential health and safety risk to the persons in care.
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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: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CAREFIELD PLEASANTON
FACILITY NUMBER: 015601206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited

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Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment ...done at least annually... This requirement is not met as evidence by:
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Based on record review, licensee did not comply with the section cited above by not having current medical assessment for some residents which poses a potential health and safety risk to the persons in care.
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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: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3