019200484-3-28-2023-15-AS-GLUK-CQCVVH-20230328164623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 03/28/2023
Date Signed: 03/28/2023 04:46:33 PM

Document Has Been Signed on 03/28/2023 04:46 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:	SUNOL CREEK MEMORY CARE		FACILITY NUMBER:	019200484
ADMINISTRATOR:	ROSE, JESSICA		FACILITY TYPE:	740
ADDRESS:	5980 SUNOL BLVD		TELEPHONE:	(925) 846-8283
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94566
CAPACITY:	46	CENSUS: 35	DATE:	03/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jacqueline Scott, Business Office Manager		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/28/2023 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Business Office Manager, Jacqueline Scott. The facility’s fire clearance was approved for 46 residents, 40 may be non-ambulatory, 6 may bedridden, and 20 residents may be under hospice care. LPA toured the facility with Jacqueline including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 7/1/2022. Weekly and daily menus were posted in dining areas. Varied activities were conducted for the residents. Facility is a memory care facility with the exit doors equipped with delayed egress. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food twice a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 38 degrees F. Comfortable temperature was maintained inside the facility. Hot water temperature was measured at 107.8 degrees F in a resident's bathroom and 106.1 degrees F in another resident's bathroom located on a different side of the facility. Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. (Continue on LIC809C...)

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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: SUNOL CREEK MEMORY CARE	FACILITY NUMBER: 019200484
	VISIT DATE: 03/28/2023

NARRATIVE

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LPA reviewed 5 resident records and 6 staff records starting at 10:55AM. Resident records were complete. LPA conducted interviews with 3 residents during inspection. Staff were fingerprint cleared and associated to the facility.

At around 2PM, LPA observed S4 did not have a completed health screening on file.

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

LPA will return at a later time to complete the inspection.

Exit interview conducted with Jacqueline Scott. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2023 04:46 PM - It Cannot Be Edited

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: SUNOL CREEK MEMORY CARE	FACILITY NUMBER: 019200484
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited by not having health screening for S4 on file which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain S4's health screening 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

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