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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200237
Report Date: 01/07/2022
Date Signed: 01/07/2022 12:35:01 PM

Document Has Been Signed on 01/07/2022 12:35 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:GARDEN TRI-VALLEYFACILITY NUMBER:
019200237
ADMINISTRATOR:HEATHER TAYLOR/WILL SANFORFACILITY TYPE:
775
ADDRESS:676 & 690 L STREETTELEPHONE:
(925) 284-3240
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 20CENSUS: 7DATE:
01/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Angelique Goldberg, Program DirectorTIME COMPLETED:
12:50 PM
NARRATIVE
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On 1/7/2022 at 10:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Personal Wellness Supervisor, Annette Winn. Program Director, Angelique Goldberg arrived 15 minutes later.

Upon entry, LPA's temperature was checked and staff completed visitor's log for LPA. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bathrooms, kitchen, common areas, and outdoor areas. LPA observed cough etiquette, signs & symptoms, and physical distancing are posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed staff have completed fit testing and provided documentation. LPA observed PPE and paper supplies are sufficient.

At 11:00AM, LPA observed unlocked scissors in the kitchen drawer and unlocked over the counter (OTC) medication belonging to staff. Staff locked up scissors and OTC medications during inspection.

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: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/07/2022 12:35 PM - It Cannot Be Edited


Created By: Grace Luk On 01/07/2022 at 12:09 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: GARDEN TRI-VALLEY
FACILITY NUMBER: 019200237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which 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 scissors and OTC medication which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/08/2022
Plan of Correction
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Staff locked up the scissors and OTC medications during inspection.

Deficency cleared during inspection.
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: 01/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2022


LIC809 (FAS) - (06/04)
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