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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601398
Report Date: 11/03/2022
Date Signed: 11/03/2022 12:06:19 PM


Document Has Been Signed on 11/03/2022 12:06 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:QUAIL GARDEN 2FACILITY NUMBER:
015601398
ADMINISTRATOR:ALICIA PEACOCKFACILITY TYPE:
740
ADDRESS:836 SOUTH J STREETTELEPHONE:
(925) 872-2705
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alicia Peacock, AdministratorTIME COMPLETED:
12:20 PM
NARRATIVE
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On 11/3/2022 at 10:00AM, Licensing Program Analysts (LPAs) G. Luk and L. Alexander arrived unannounced to conduct an Infection Control Inspection. LPAs met with caregiver, Angela, Dela Cruz and explained the purpose of the visit. Administrator, Alicia Peacock arrived 30 minutes later

Upon entry, staff did not conduct COVID-19 screen for LPAs. LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to residents' bedrooms, bathrooms, kitchen, dining area, garage, and outdoor areas. LPAs observed physical distancing, signs & symptoms, and mask wearing posted in the common areas. All bathrooms were equipped with soap and paper towel. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log and temperature logs. LPAs observed facility has a copy of Mitigation Plan on file. Staff completed FIT testing for N95 respirators and have completion documents. LPAs observed PPE, food supplies, and paper supplies are sufficient.

At 10:14AM, LPAs observed unlocked medications in the kitchen cabinet. Staff locked up the medications during visit.

At 10:20AM, LPAs observed keys were on the locked knives drawers and accessible. LPAs observed unlocked lighters, laundry detergent, and cleaning supplies. Staff locked up the items during inspection.

(Continue on LIC9099C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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 6


Document Has Been Signed on 11/03/2022 12:06 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: QUAIL GARDEN 2
FACILITY NUMBER: 015601398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 hot water meausred at 131.9 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Administrator has agreed to lower hot water and submit picture proof to CCLD by POC date.
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, lighters, and detergents which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Staff locked up items during inspection.

Deficiency cleared.

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: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 11/03/2022 12:06 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: QUAIL GARDEN 2
FACILITY NUMBER: 015601398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 medications which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Staff locked up medications during inspection.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


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: QUAIL GARDEN 2
FACILITY NUMBER: 015601398
VISIT DATE: 11/03/2022
NARRATIVE
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At 10:27AM, LPAs observed hot water was measured at 131.9 degrees F in the hallway bathroom sink.

At 10:32AM, LPAs observed R1's room was an entrance to the garage and staff was using R1's room to access the garage.

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 Alicia. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/03/2022 12:06 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: QUAIL GARDEN 2
FACILITY NUMBER: 015601398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(C)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function....The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
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 R1's bedroom as a passageway to the garage which poses a potential personal rights violation to persons in care.
POC Due Date: 11/21/2022
Plan of Correction
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Administrator agreed to conduct training to staff to not use R1's bedroom as a passageway to the garage. Administrator will submit staff sign-in sheet to CCLD by POC date.
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: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6