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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601270
Report Date: 12/03/2021
Date Signed: 12/03/2021 02:35:17 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:A GABRIELA'S VILLA-LIVERMOREFACILITY NUMBER:
015601270
ADMINISTRATOR:TRINIDAD, DUMITELA A.FACILITY TYPE:
740
ADDRESS:1051 LYNN STREETTELEPHONE:
(925) 998-4316
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Dumitela Trinidad, LicenseeTIME COMPLETED:
02:50 PM
NARRATIVE
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On 12/3/2021 at 12:55PM, Licensing Program Analysts (LPAs) G. Luk and J. Clancy-Czuleger arrived unannounced to conduct an Infection Control Inspection. LPAs met with licensee, Dumitela Trinidad and explained the purpose of the visit.

Upon entry, LPAs' temperature were checked, and LPAs observed hand sanitizer and hand washing sign at screening station. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage, and outdoor area. LPAs observed cough etiquette and physical distancing posted in the common areas. All sinks were equipped with soap and paper towel.

During record review, LPAs observed visitors log and temperature log. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPE, food, and paper supplies are sufficient.

At 1:10PM, LPAs observed an unlocked bottle of vitamins. Staff locked up the bottle during inspection.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional 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: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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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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: A GABRIELA'S VILLA-LIVERMORE
FACILITY NUMBER: 015601270
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 vitamins in the kitchen cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/04/2021
Plan of Correction
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Staff locked the vitamins 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: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021
LIC809 (FAS) - (06/04)
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