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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200764
Report Date: 04/01/2022
Date Signed: 04/01/2022 12:30:58 PM


Document Has Been Signed on 04/01/2022 12:30 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:LIVERMORE VALLEY SENIOR CAREFACILITY NUMBER:
019200764
ADMINISTRATOR:DONG, ZHIYONGFACILITY TYPE:
740
ADDRESS:3356 EAST AVENUETELEPHONE:
(925) 447-5483
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:20CENSUS: 0DATE:
04/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Paul Zhu, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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On 4/1/2022 at 10:48AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Paul Zhu.

Upon entry, staff did not conduct COVID-19 screening for LPA. Facility does not have residents currently and does not have screening station set up. Administrator stated that when residents were here, there was a COVID-19 screening station set up. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. Facility did not have any COVID-19 signs posted in common areas.

During record review, LPA observed facility has a copy of Mitigation Plan on file.

Per Administrator, facility relocated residents in February 2022 and notified the residents & family members. However, CCLD (Community Care Licensing Division) was not provided this information until residents were moved out. Eviction notice was not given to CCLD.

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

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
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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Document Has Been Signed on 04/01/2022 12:30 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: LIVERMORE VALLEY SENIOR CARE
FACILITY NUMBER: 019200764

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87224(c)
87224 Eviction Procedures
(c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person.

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 providing eviction notice to CCLD which poses a potential health and safety risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
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Administrator has agreed to review the Eviction Procedures regulation and submit self-certification 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
LIC809 (FAS) - (06/04)
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