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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200764
Report Date: 02/08/2023
Date Signed: 02/08/2023 05:11:15 PM


Document Has Been Signed on 02/08/2023 05:11 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: 6DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Elizabeth Nagy, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 2/8/2023 at 2:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Elizabeth Nagy.

Upon entry, LPA's temperature was checked and asked to fill out visitor's log. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA observed cough etiquette, signs & symptoms, and physical distancing are posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms.

During record review, LPA observed visitors log and temperature log for residents. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient.

At 2:40PM, LPA observed unlocked cleaning supplies in the hallway closet. Staff locked up the cleaning supplies during inspection.

At 2:45PM, LPA measured hot water temperature at 128 degrees F in the hallway bathroom sink.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies 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: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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 02/08/2023 05:11 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: 02/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having hot water at 128 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/09/2023
Plan of Correction
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Administrator has agreed to adjust hot water temperature and submit picture proof to CCLD by POC date.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/09/2023
Plan of Correction
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Staff locked up cleaning supplies during inspection.

Deficiency cleared.
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: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
LIC809 (FAS) - (06/04)
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