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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200764
Report Date: 07/22/2024
Date Signed: 07/22/2024 05:37:26 PM


Document Has Been Signed on 07/22/2024 05:37 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:
07/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Rachell Paniagua, AdministratorTIME COMPLETED:
05:50 PM
NARRATIVE
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On 7/22/2024 at 5:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection due to a change of ownership. LPA met with Administrator, Rachell Paniagua.

During Pre-licensing Inspection, LPA observed the following deficiencies:

At 1:30PM, LPA observed unlocked cleaning supplies in the bathroom and kitchen area. Staff locked up cleaning supplies during inspection.

At 1:40PM, LPA observed a bag of soil stored in the pantry area with food items. Staff locked up the soil during inspection.

At 1:50PM, LPA observed hot water was measured at 124 degrees F in the hallway bathroom. Staff lowered hot water temperature and LPA re-measured hot water at 109.7 degrees F.

At 2:10PM, LPA observed back yard area has lots of items to be disposed including hoyer lift, bed frames, water heater, wheelchairs, and other items.

At 2:15PM, LPA observed back yard area has some benches. However, there was no shaded areas for residents.

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



Exit interview conducted. A copy of this report, civil penalties, and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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 4


Document Has Been Signed on 07/22/2024 05:37 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: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2024
Section Cited
CCR
87309(a)

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Storage Space. Disinfectants, cleaning solutions...and other items which could pose a danger ...shall be stored where inaccessible to clients.
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Staff locked up the cleaning supplies during inspection.

Deficiency cleared.
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This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by having cleaning supplies unlocked which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $250 is being assessed for repeat violation.
Type A
07/23/2024
Section Cited
CCR87303(e)(2)

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Maintenance and Operation. Hot water temperature controls shall be maintained...not less than 105 degree F...and not more than 120 degree F...
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Staff lowered hot water temperature during inspection.

Deficiency cleared.
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This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by having hot water at 124 degrees F which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $250 is being assessed for repeat violation.
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: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 07/22/2024 05:37 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: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2024
Section Cited
CCR
87555(b)(25)

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General Food Service Requirements. Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.
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Staff removed bag of soil in the pantry area.

Deficiency cleared.
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This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by storing soil with food items which poses a potential health and safety risk to the persons in care.
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Type B
08/05/2024
Section Cited
CCR87303(a)

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by:
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Administrator has agreed to remove the items to be dispose and submit picture proof to CCLD by POC date.
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Based on observation, licensee did not comply with the section cited above by having disposable items stored in the back yard area 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: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/22/2024 05:37 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: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2024
Section Cited
CCR
87219(h)(2)

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Planned Activities. Outdoor activity areas which are easily accessible to residents and...shall be sufficient in size, comfortable...for outdoor use.
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Administrator has agreed to obtain outdoor furniture which includes shaded outdoor space for residents and submit picture proof/receipt to CCLD by POC date.
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This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by not having shaded area in the back yard for residents 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: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4