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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200468
Report Date: 08/03/2021
Date Signed: 08/03/2021 05:29:01 PM

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:EASY LIVING CARE HOME-MEADOWLARKFACILITY NUMBER:
019200468
ADMINISTRATOR:CAROLINE YANKILINGFACILITY TYPE:
740
ADDRESS:538 MEADOWLARK STREETTELEPHONE:
(925) 989-3345
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 4DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Grace Del Rosario, AdministratorTIME COMPLETED:
05:40 PM
NARRATIVE
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On 08/03/2021 at 3:00pm, Licensing Program Analysts (LPAs) C. Fowler and G. Luk arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Grace Del Rosario and explained the purpose of the visit.

Upon entry, LPA's temperatures were checked by staff. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPAs observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log and temperature logs for residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed food and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 3:15PM, LPAs observed resident had full bed rail and not on hospice care.
-At 3:30PM, LPAs observed staff was not associated to the facility.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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 6
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: EASY LIVING CARE HOME-MEADOWLARK
FACILITY NUMBER: 019200468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)


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 not associating staff to facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/04/2021
Plan of Correction
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Administrator will submit LIC 9182 and a copy of current US ID to CCLD by POC date.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.


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 in by having full bed rails for resident who is not on hospice care which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/04/2021
Plan of Correction
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Administrator has agreed to remove full bed rail and submit picture proof 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021
LIC809 (FAS) - (06/04)
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