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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200186
Report Date: 12/07/2023
Date Signed: 12/07/2023 05:30:20 PM

Document Has Been Signed on 12/07/2023 05:30 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: 6DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lorna Hayag, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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On 12/7/2023 at 10:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Lorna Hayag and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, shed, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 8/25/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 111.7 degrees F in the kitchen sink. There were adequate lights in each room. First Aid kit is complete. Last fire drill was conducted on 11/28/2023.

LPA reviewed 5 client and 5 staff files starting at 12:10PM. LPA interviewed 2 residents and 2 staff at 1:45PM. LPA reviewed a sample of resident's medications starting at 4:00PM.

At 11:21AM, LPA observed unlocked medications in the kitchen drawer. Staff locked up the medications during inspection.

At 11:25AM, LPA was informed by administrator that other clients have used the bathroom in C1 & C2's room.

At 11:35AM, LPA observed the shed in the backyard has a bed and was informed by administrator/staff that staff sometimes sleep/rest in the shed.

(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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: MCHAROLD HOME
FACILITY NUMBER: 019200186
VISIT DATE: 12/07/2023
NARRATIVE
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At 12:50PM, LPA observed C2 does not have a TB test results on file.

At 3:50PM, LPA observed facility have not completed LIC610D and mass casualty plan.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/07/2023 05:30 PM - It Cannot Be Edited


Created By: Grace Luk On 12/07/2023 at 04:20 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: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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 in the kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Staff locked up the 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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/07/2023 05:30 PM - It Cannot Be Edited


Created By: Grace Luk On 12/07/2023 at 04:20 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: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)(A)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by having staff sleeping in the shed which poses a potential health and safety risk to persons in care.
POC Due Date: 12/11/2023
Plan of Correction
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Administrator has agreed to remove the bed in the shed and will not have staff sleep/rest in the shed in the future. Administrator will submit picture proof to CCLD by POC date.
Type B
Section Cited
CCR
85087(a)(4)
Building and Grounds
(4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by having other clients use the bathroom in C1 & C2's room which poses a potential personal rights violation to persons in care.
POC Due Date: 12/18/2023
Plan of Correction
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Administrator has agreed to conduct an in-service regarding personal rights and submit staff sign-in sheet by POC date.
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: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/07/2023 05:30 PM - It Cannot Be Edited


Created By: Grace Luk On 12/07/2023 at 04:20 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: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above not having TB test result for C2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2024
Plan of Correction
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Administrator has agreed to obtain TB test for C2 and submit a copy to CCLD by POC date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having LIC610D & mass casualty plan completed which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2023
Plan of Correction
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Administrator has agreed to complete LIC610D & mass casualty plan and submit a copy to CCLD by POC date.
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: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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