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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200676
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:49:09 PM

Document Has Been Signed on 05/10/2024 03:49 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:H & M HOMES LLCFACILITY NUMBER:
019200676
ADMINISTRATOR/
DIRECTOR:		GRACE G. PACLEBFACILITY TYPE:
740
ADDRESS:40726 WOLCOTT DRIVETELEPHONE:
(510) 656-3664
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
05/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Olive Neri, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 5/10/2024 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Administrator, Olive Neri and explained the purpose of the visit.

During visit, LPA reviewed 6 residents' files and 4 staff files. LPA observed resident's files and staff files were complete. Staff have current first aid and CPR training. LPA observed staff completed training which includes dementia, medication, and other topics. LPA reviewed residents' P&I money with log. LPA observed facility has a surety bond and last fire drill was conducted on 3/20/2024.

LPA reviewed resident's medications at around 1:00PM. LPA interviewed 2 residents and 3 staff starting at 2:30PM.

At around 2:00PM, LPA observed R6 has a doctor's order for Melatonin 3mg daily. However, facility has a bottle of Melatonin 5mg. LPA was informed by staff that R6 was last given Melatonin in March 2024 and R6 is not currently taking Melatonin. There was no D/C (discontinue) order for R6's Melatonin.

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.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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 05/10/2024 03:49 PM - It Cannot Be Edited


Created By: Grace Luk On 05/10/2024 at 03:32 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: H & M HOMES LLC
FACILITY NUMBER: 019200676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not following doctor's orders for R6's medication which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/11/2024
Plan of Correction
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Administrator has agreed to obtain Melatonin 3mg for R6 and submit picture proof to CCLD by POC date.
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: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
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