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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200764
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:18:48 PM


Document Has Been Signed on 01/19/2023 01:18 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: 7DATE:
01/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
01:30 PM
NARRATIVE
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On 1/19/2023 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with manager, Rachell Paniagua

While LPA was conducting a complaint investigation, the following deficiencies were observed.

At 10:30AM, LPA observed S1 was not associated to the facility and have been working since November 2022. Civil penalty of $500 is being assessed.

At 12:30PM, LPA observed facility does not have land line phone on premises.

At 12:35PM, LPA observed facility does not have 7-day supply of non-perishable foods.


The deficiencies were 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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 3


Document Has Been Signed on 01/19/2023 01:18 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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review...Request a transfer of a criminal record clearance as specified in Section 87355(c)...This requirement is not met as evidence by:
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Facility has agreed to associate her to the facility and to submit documents to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by having non-associated staff work at the facility which posese an immediate health and safety risk to the persons in care.
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Civil penalty of $500 is being assessed.
Type B
02/03/2023
Section Cited

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Telephones
All facilities shall have telephone service on the premises.
This requirement is not met as evidence by:
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Facility has agreed to put in a land line in and will submit installation receipt to CCLD by POC date.
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Based on observation, licensee did not comply with the section cited above by not having a land line at the facility which poses a potential health and safety risk to the persons in care.
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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: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/19/2023 01:18 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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited

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General Food Service Requirements. Supplies of nonperishable foods for a minimum of one week...shall be maintained on the premises. This requirement is not met as evidence by:
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Facility has agreed to purchase non-perishable foods and submit receipt to CCLD by POC date.
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Based on observation, licensee did not comply with the section cited above by not having 7-day of non-perishable food supplies which poses a potential health and safety risk to the persons in care.
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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: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3