015601285-5-3-2024-15-AS-LHOS-D4WUPW-20240503154612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601285
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:46:28 PM

Document Has Been Signed on 05/03/2024 03:46 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:	RAKSHA 13 CARE HOME		FACILITY NUMBER:	015601285
ADMINISTRATOR:	BHUTANI, SHALINI		FACILITY TYPE:	740
ADDRESS:	906 CORNELL AVENUE		TELEPHONE:	5105262533
CITY:	ALBANY	STATE: CA	ZIP CODE:	94706
CAPACITY:	13	CENSUS: 11	DATE:	05/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nalini Bhutani, Co-Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/03/24 around 09:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required Annual Inspection. LPA was greeted by one Care Staff upon entry and explained the purpose of the visit; Nalini Bhutani, Co-Administrator (ADM) arrived about 20 minutes later. The facility’s fire clearance was approved for thirteen (13) non-ambulatory residents; hospice waivers for four (4). LPA reviewed the resident roster, staff roster, five (5) staff files, five (5) resident files and the Emergency Disaster Plan. LPA observed a visitor sign-in log at the entry. LPA and ADM toured the facility, including but not limited to bedrooms, two (2) bathrooms (BA), kitchen, common area, front yard and backyard. The facility consists of seven (7) total bedrooms. All indoor passageways were free of obstruction. There were not any bodies of water. Five (5) residents were lounging in the front yard, one (1) reading a newspaper, the others were either sleeping, watching television or engaged in electronics in the facility. A comfortable temperature for residents was maintained at 72 degrees Fahrenheit (F), and the water temperature measured at 111 (F) in BA #1. LPA observed lighting in all rooms to be adequate for the comfort and safety of all the residents. The bathrooms were safe, sanitary and in operating condition. Hand washing posters, paper towels, and soap observed at all hand washing stations. Linen and hygiene supplies were available for all residents. PPE and paper goods remain sufficient. There is a minimum supply of 2-day perishables and 7-days of non-perishable foods. continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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: RAKSHA 13 CARE HOME	FACILITY NUMBER: 015601285
	VISIT DATE: 05/03/2024

NARRATIVE

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...continued from LIC809

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 01/22/24, first aid kit is stored in a locked medication room, and the last emergency disaster drill was conducted on 04/01/24 with all staff; next quarterly drill to include staff and residents.

The following forms are to be updated:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610D Emergency Disaster Plan to be updated.
-An updated copy of Administrator Certificate(s)
-Update personnel files

Exit interview conducted and a copy of this report provided to Nalini Bhutani, Administrator.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/03/2024 03:46 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: RAKSHA 13 CARE HOME	FACILITY NUMBER: 015601285
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the Administrator did not comply with the section cited above by not renewing the the Standard Certificate #6012203740 that expired 05/31/2023 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	The Administrator will provide dccumentation for renewal of the Standard Certficate by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC809 (FAS) - (06/04)

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