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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601270
Report Date: 12/08/2022
Date Signed: 12/08/2022 01:04:18 PM


Document Has Been Signed on 12/08/2022 01:04 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: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: 4DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Florante Tanjuatco, CaregiverTIME COMPLETED:
01:20 PM
NARRATIVE
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On 12/8/2022 at 11:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with caregiver, Florante Tanjuatco and explained the purpose of the visit. Licensee, Dumitela Trinidad was unable to be at the facility and stated that caregiver can sign the report.

Upon entry, staff checked LPA's temperature and LPA was asked to fill out visitor's log. LPA observed hand sanitizer at screening station. LPA toured facility including but not bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPA observed cough etiquette and physical distancing posted in the common areas. All sinks were equipped with soap and paper towel. Hot water was measured at 110.3 F in the hallway bathroom.

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

At 11:15AM, LPA observed an unlocked cleaning supplies in the hallway closet and garage. Staff locked up the cleaning supplies during inspection.

At 11:20AM, LPA observed hallway toilet seat cover was broken with a crack and living room screen door had an opening.

At 11:50AM, LPA observed S1 does not have health screening and TB test completed during record review.

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: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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 5


Document Has Been Signed on 12/08/2022 01:04 PM - It Cannot Be Edited

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: 12/08/2022

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 cleaning supplies in the hallway closet and garage which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Staff locked up the cleaning supplies in the hallway closet and garage during inspection.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 12/08/2022 01:04 PM - It Cannot Be Edited

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: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 not having health screening and TB test completed for S1 which poses a potential health and safety risk to persons in care.
POC Due Date: 12/19/2022
Plan of Correction
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Staff has agreed to complete health screening and TB test. Administrator will submit a copy of S1's health screening and TB test 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: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 12/08/2022 01:04 PM - It Cannot Be Edited

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: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 toilet seat cover and screen door in disrepair which poses a potential health and safety risk to persons in care.
POC Due Date: 12/19/2022
Plan of Correction
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Staff has agreed to replace the cracked seat cover and repair the screen door in the living room. Administrator will submit pictures proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5