019200853-3-13-2025-15-AS-GLUK-DER3VR-20250313183534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200853
Report Date: 03/13/2025
Date Signed: 03/13/2025 06:36:01 PM

Document Has Been Signed on 03/13/2025 06:36 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 CARE HOME		FACILITY NUMBER:	019200853
ADMINISTRATOR/ DIRECTOR:	SANDHU, SEEMA		FACILITY TYPE:	740
ADDRESS:	1542 PERIDOT DR		TELEPHONE:	(510) 825-2383
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Madeena Siddiqi, Staff		TIME VISIT/ INSPECTION COMPLETED:	06:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/13/2025 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Caregiver, Lawrence Walker and explained the purpose of the visit. Staff, Madeena Siddiqi arrived a couple hours later. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. First Aid kit is complete. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 2/18/2025. One week supply of nonperishable and 2-day supply of perishable foods were available. Grab bars for each shower and toilet were installed. Non-skid mats/material were observed. There were adequate lights in each room. LPA reviewed 5 residents and 4 staff records starting at 10:30AM. LPA reviewed a sample of resident's medications and MAR (Medication Administration Record). At 10:00AM, LPA observed unlocked lighters and cleaning supplies in kitchen. Staff locked up the items during inspection. At 10:05AM, LPA observed unlocked medications in the refrigerator and cabinet. Staff locked up the medication found in the cabinet. At 10:10AM, LPA observed hot water was measured at 128 degrees F in the hallway bathroom. At 12:30PM, LPA observed on Guardian that S4 is not fingerprint cleared and was assisting residents. S4 left the facility during inspection. 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 with Madeena Siddiqi. A copy of this report, civil penalties, and appeal rights were provided.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Grace Luk	TELEPHONE: (510) 286-4201
	DATE: 03/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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 03/13/2025 06:36 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 CARE HOME	FACILITY NUMBER: 019200853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having hot water measured at 128 degrees F which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	Facility has agreed to lower hot water temperature between 105 to 120 degrees and submit picture proof to CCLD by POC date.

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked lighters and cleaning supplies which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	Staff locked up the lighter and cleaning supplies during inspection. Civil penalty of $250 is being assessed for a repeat violation. 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.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Grace Luk	TELEPHONE: (510) 286-4201
	DATE: 03/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/13/2025 06:36 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 CARE HOME	FACILITY NUMBER: 019200853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the refrigerator and cabinet which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	Facility has agreed to purchase a lockbox to lock up the medications in the refrigerator and submit picture proof to CCLD by POC date.

Type A

Section Cited

CCR

87355(e)(2)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee did not comply with the section cited above by having uncleared staff work at the facility which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	S4 left the facility during inspection and administrator stated that S4 will not be returning to the facility until S4 is cleared and associated to the facility. Facility will submit a plan to get S4 fingerprint cleared prior to returning to the facility. Civil penalty of $100 is being assessed.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Grace Luk	TELEPHONE: (510) 286-4201
	DATE: 03/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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