019200505-7-5-2022-15-AS-LFII-CG2SQC-20220705140430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200505
Report Date: 07/05/2022
Date Signed: 07/05/2022 02:04:46 PM

Document Has Been Signed on 07/05/2022 02:04 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:	BELOVED HOME RETREAT		FACILITY NUMBER:	019200505
ADMINISTRATOR:	BYRON TRIPP		FACILITY TYPE:	740
ADDRESS:	41223 CHILTERN DRIVE		TELEPHONE:	(510) 656-9654
CITY:	FREMONT	STATE: CA	ZIP CODE:	94539
CAPACITY:	6	CENSUS: 3	DATE:	07/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Administrator- Mirriam Paras		TIME COMPLETED:	02:10 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 today’s date, Licensing Program Analysts (LPAs) L. Fici and C. Lin arrived unannounced to conduct an annual Infection Control Inspection. LPAs met with care staff Bubby Paclar explained the purpose of visit. Mirriam Paras Administrator (ADM) arrived soon after at 11:30am and greeted by LPAs. LPAs toured facility with ADM including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Temperature of facility is maintained at 74 degrees F. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Continue on Lic809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

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: BELOVED HOME RETREAT	FACILITY NUMBER: 019200505
	VISIT DATE: 07/05/2022

NARRATIVE

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Continued on Lic809C

The following deficiencies were observed during inspection:
1. 10:40am LPAs observed S1 with no fingerprint clearance working in the kitchen of the facility. Administrator admitted that S1 was volunteer and has not completed criminal background check clearance. S1 was removed from facility during visit.
2. 10:45am LPAs observed a pair of scissors and knife accessible to 2 dementia residents in care.
3. 10:45am LPAs observed a greasy broken cabinet with no hinges above the stove.
4. 10:48am LPAs observed Lactulose Solution and various medications belonging to residents on the kitchen counter that were accessible.
5. 11:00am LPAs observed cleaning supplies accessible to persons in care.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. A civil penalty was assessed for the amount of $500

The following forms are to be updated and submitted to CCLD By 7/12/2022.

- LIC500- Personnel Report
- LIC308- Designation of Administrative Responsibility
- LIC610E- Emergency Disaster Plan

Exit interview conducted with Administrator and a copy of this report provided along with Appeal rights.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/05/2022 02:04 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: BELOVED HOME RETREAT	FACILITY NUMBER: 019200505
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

Criminal clearance: (e) An applicant and any other person specified in subdivision (b) shall submit fingerprint images and related information to the Department of Justice and the Federal Bureau of Investigation… (1) adult responsible for administration or direct supervision of staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing a staff member work in the facility without having fingerprint clearance which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/06/2022
	Plan of Correction
1 2 3 4	Administrator removed S1 during visit. Administrator agreed to submit a self-certification to CCL by explaining that no Staff shall work in the facility without proper fingerprint clearance by POC due date.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not locking up sharps and pair of scissors that were accessible to dementia residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/06/2022
	Plan of Correction
1 2 3 4	Deficiency cleared. Administrator locked up sharps and medications during visit.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/05/2022 02:04 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: BELOVED HOME RETREAT	FACILITY NUMBER: 019200505
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having prepared residents medication on the kitchen counter, and having cleaning supplies accessible to residents in the laundry room unlocked which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/06/2022
	Plan of Correction
1 2 3 4	Administrator purchased and replaced pad locks which locked all medications and cleaning supplies. Deficiency cleared

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/05/2022 02:04 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: BELOVED HOME RETREAT	FACILITY NUMBER: 019200505
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having unrepaired and greasy cabinets in the facility which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/12/2022
	Plan of Correction
1 2 3 4	Adminstrator agreed to fix and clear the kitchen cabinet(s) and to submit a photo copy to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC809 (FAS) - (06/04)

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