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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601411
Report Date: 04/07/2021
Date Signed: 04/07/2021 02:56:09 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:WELCOME HOME SENIOR RESIDENCE (PLEASANTON)FACILITY NUMBER:
015601411
ADMINISTRATOR:VELASCO,J & CHOU, SFACILITY TYPE:
740
ADDRESS:6839 SINGLETREE COURTTELEPHONE:
(510) 685-8388
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:6CENSUS: 5DATE:
04/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Julita VelascoTIME COMPLETED:
03:00 PM
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On 04/07/2021 Licensing Program Analyst (LPA) Allison O'Hollaren conducted an unannounced case management visit regarding a self reported incident. Due to the Shelter in Place set forth by the Governor on March 17, 2020, LPA was not able to conduct the visit in person. The visit was performed by telephone. LPA spoke with Administrator, Julita Velasco.

According to Administrator, Resident R1 had two different medication lists with one different medication on each list for blood pressure. Administrator asked the family of R1 to obtain one of the medications that was not on the other medication list and was not included in the resident's medication supply. On 03/10/2021 after the facility administered medications for R1, Administrator realized around eight hours later that the two medications given to R1 were the same medications under two different generic names. Facility notified a Kaiser Nurse and Poison Control and then per Poison Control recommendations, the family of R1 took resident to the hospital. Resident did not have side effects due to the additional dosage of medication and was released from the hospital. Administrator stated the facility is now double-checking all medication lists to ensure medications are not duplicates under different generic names.

No deficiencies cited during visit. Exit interview conducted and a copy of the report emailed to Administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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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