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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200186
Report Date: 12/02/2022
Date Signed: 12/02/2022 01:06:17 PM

Document Has Been Signed on 12/02/2022 01:06 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:MCHAROLD HOMEFACILITY NUMBER:
019200186
ADMINISTRATOR:LORNA A.HAYAGFACILITY TYPE:
735
ADDRESS:1076 EL DORADO DRIVETELEPHONE:
(925) 245-0779
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 5DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Ernesto Golez, Licensee/ Back-up AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
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On 12/2/2022 at 10:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with staff, Espedieto Patricio. Licensee/ back-up administrator, Ernesto Golez arrived 30 minutes later.

Upon entry, staff did not conduct COVID-19 screening for LPA. However, staff later checked LPA's temperature and asked to fill out visitor's log. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor area. LPA observed cough etiquette, signs & symptoms, and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitor's log and temperature log for clients and staff. LPA observed facility does have a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient.

At 11:20AM, LPA observed unlocked paint, fluid lighter, and gardening tools in the shed in the back yard. Staff locked up the storage shed during inspection.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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Document Has Been Signed on 12/02/2022 01:06 PM - It Cannot Be Edited


Created By: Grace Luk On 12/02/2022 at 12:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MCHAROLD HOME
FACILITY NUMBER: 019200186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 paint, fluid lighter, and gardening tools in the shed which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/03/2022
Plan of Correction
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Staff locked up the paint, fluid lighter, and gardening tools in the shed 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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022


LIC809 (FAS) - (06/04)
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