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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200779
Report Date: 07/05/2023
Date Signed: 07/05/2023 05:04:20 PM

Document Has Been Signed on 07/05/2023 05:04 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:ANDALUCIA HOMEFACILITY NUMBER:
019200779
ADMINISTRATOR:LEGARDA, MARISSAFACILITY TYPE:
735
ADDRESS:1083 ANDALUCIA STREETTELEPHONE:
(650) 892-9264
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 4CENSUS: 4DATE:
07/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Marissa Legarda, AdministratorTIME COMPLETED:
05:18 PM
NARRATIVE
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On 7/5/2023 at 12:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with staff, Marlo Legarda. Administrator, Marissa Legarda arrived an hour later. The facility’s fire clearance was approved for 4 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 5/2/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 117.6 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathroom. There were adequate lights in each room. First Aid kit is complete. No bodies of water observed. Indoor and outdoor passageways were free of obstruction.

LPA reviewed 4 client and 3 staff files starting at 1:30PM. LPA reviewed a sample of client's medications starting at 2:50PM. LPA interviewed 2 clients and 2 staff starting at 3:45PM.

At 2:20PM, LPA observed clients does not have current needs and service plans on file.

At 2:30PM, LPA observed clients does not have functional capability assessment on file.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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 07/05/2023 05:04 PM - It Cannot Be Edited


Created By: Grace Luk On 07/05/2023 at 04:24 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: ANDALUCIA HOME
FACILITY NUMBER: 019200779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

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 having a current needs and service plan which poses a potential health and safety risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Administrator has agreed to obtain current needs and service plans for all clients and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:

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 having functional capabilities assessment which poses a potential health and safety risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Administrator has agreed to obtain functional capabilities assessment for all clients and submit a copy to CCLD by POC date.
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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/05/2023 05:04 PM - It Cannot Be Edited


Created By: Grace Luk On 07/05/2023 at 04:24 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: ANDALUCIA HOME
FACILITY NUMBER: 019200779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(13)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (13) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not providing food preparation training for staff which poses a potential health and safety risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Administrator has agreed to provide training for staff on food preparation and submit certificates 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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
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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: ANDALUCIA HOME
FACILITY NUMBER: 019200779
VISIT DATE: 07/05/2023
NARRATIVE
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At 2:40PM, LPA observed staff does not have food preparation training.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies 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: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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