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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200186
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:01:02 PM

Document Has Been Signed on 12/10/2024 03:01 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/
DIRECTOR:		LORNA A.HAYAGFACILITY TYPE:
735
ADDRESS:1076 EL DORADO DRIVETELEPHONE:
(925) 245-0779
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Lorna Hayag, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 12/10/2024 at 10:00AM, 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.

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 8/12/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 107.5 degrees F in the hallway bathroom sink. There were adequate lights in each room. First Aid kit is complete. Last fire drill was conducted on 10/27/2024.

LPA reviewed 6 clients and 5 staff files starting at 11:20AM. LPA reviewed client's P&I money with log. LPA interviewed 2 staff during inspection. LPA reviewed a sample of client's medications at around 1:00PM.

At 11:00AM, LPA observed a wooden stick on the tracks of the sliding glass door in the living room to prevent the door from opening. LPA was informed the stick is place there to prevent C1 from opening the sliding glass door at night. Staff removed the wooden stick from the tracks during inspection. LPA observed other exit doors and side gate were not locked from the inside.

The 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. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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Document Has Been Signed on 12/10/2024 03:01 PM - It Cannot Be Edited


Created By: Grace Luk On 12/10/2024 at 02:21 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(7)
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(7) Not to be locked in any room, building, or facility premises by day or night.
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 using a wooden stick to prevent the sliding glass door from opening which poses a potential health and safety risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Administrator has agreed to conduct training regarding personal rights and submit staff sign-in sheet with materials 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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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