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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200237
Report Date: 01/09/2024
Date Signed: 01/09/2024 04:53:43 PM

Document Has Been Signed on 01/09/2024 04:53 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: 8DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Ciara Vasquez, Program CoordinatorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 1/9/2024 at 12:40PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Program Coordinator, Ciara Vasquez. The facility’s fire clearance was approved for 20 non-ambulatory clients.

LPA toured the facility including but not limited to activity rooms, resting room, common areas, bathrooms, kitchen, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 9/22/2023. Clients bring lunches from home/residential facilities. Hot water temperature in the hallway bathroom was measured at 112.4 degrees F. All observed toilets and hand washing stations are maintained in a safe, sanitary, and operating condition. There are no bodies of water observed. First aid kit was complete.

LPA reviewed 3 clients and 3 staff files starting at 1:20PM. LPA interviewed 3 clients and 3 staff starting at 2:00PM.

At 1:09PM, LPA observed unlocked cleaning supplies under the bathroom sink. Staff locked up the cleaning supplies during inspection.

At 1:30PM, LPA observed facility does not have medical assessments (LIC602) for C1, C2, and C3 on file.

At 3:30PM, LPA observed facility does not have disaster drill documents on file.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. 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: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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 01/09/2024 04:53 PM - It Cannot Be Edited


Created By: Grace Luk On 01/09/2024 at 04:37 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: 01/09/2024

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 cleaning supplies accessible to clients which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
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Staff locked up the cleaning supplies during inspection.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/09/2024 04:53 PM - It Cannot Be Edited


Created By: Grace Luk On 01/09/2024 at 04:37 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: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

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 medical assessment for 3 clients which poses a potential health and safety risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Facility has agreed to obtain medical assessments for C1, C2, and C3. Facility will submit copies of the medical assessments to CCLD by POC date.
Type B
Section Cited
CCR
82023(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

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 disaster drill records available which poses a potential health and safety risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Facility has agreed to conduct disaster drill and submit record 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: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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