015601429-5-29-2024-15-AS-LHOS-D5R5XN-20240529202057

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601429
Report Date: 05/29/2024
Date Signed: 05/29/2024 08:22:20 PM

Document Has Been Signed on 05/29/2024 08:22 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 4 CARE HOME		FACILITY NUMBER:	015601429
ADMINISTRATOR:	BHUTANI, BHUMI		FACILITY TYPE:	740
ADDRESS:	616 STANNAGE AVENUE		TELEPHONE:	(510) 912-6244
CITY:	ALBANY	STATE: CA	ZIP CODE:	94706
CAPACITY:	6	CENSUS: 6	DATE:	05/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Sumitra Khadka, Caregiver		TIME COMPLETED:	05:15 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 05/29/24 around 01:45 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required Annual Inspection. LPA was greeted by Sumitra Khadka, Caregiver (S1) and Co-Administrator Shalini Bhutani (ADM) was telephoned and agreed to have S1 sign the report. The facility’s fire clearance was approved for six (6) non-ambulatory residents; hospice waivers for three (3). Upon entry LPA explained the purpose of the visit. LPA reviewed the resident roster, resident and staff files, and Emergency Disaster Plan. LPA observed a visitor sign-in log at the entry. LPA and S1 toured the facility, including but not limited to bedrooms, bathroom, kitchen, laundry room, common area, front yard and backyard. The facility consists of four (4) total bedrooms. All indoor passageways were free of obstruction. There aren't any bodies of water. A comfortable temperature for residents was maintained at 73 degrees Fahrenheit (F), and the water temperature measured at 114.6 for the comfort and safety of all the residents. The bathroom was safe, sanitary and in operating condition. Hand washing posters, paper towels, and soap observed at 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: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 4 CARE HOME	FACILITY NUMBER: 015601429
	VISIT DATE: 05/29/2024

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 observed complete and next emergency disaster to be conducted on or before 06/01/2024.

The following forms are to be updated and submitted to CCLD on or before 06/01/24:
- LIC 610D Emergency Disaster Plan
- Facility sketch
- LIC 200
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility (Reviewed)
--An updated copy of Administrator Certificate(s)

The following deficiency was observed.
-At 3:20 PM, LPA observed there was not an updated fire clearance inspection for two (2) of the six (6) ambulatory and non-ambulatory residents.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted, Appeal Rights and a copy of this report provided to S1.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/29/2024 08:22 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 4 CARE HOME	FACILITY NUMBER: 015601429
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, interviews and records review, the licensee did not comply with the section cited above in two (2) out of six (6) residents being identified as bedridden and not approved on the fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/01/2024
	Plan of Correction
1 2 3 4	The licensee will submit an LIC 200 and an updated facility sketch for bedridden capacity to CCLD for two (2) out of the six (6) residents being identified as bedridden.

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: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC809 (FAS) - (06/04)

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