Community Care Licensing

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022

Document Has Been Signed on 04/28/2022 03:40 PM - It Cannot Be Edited

FACILITY NAME: MAMA'S LOVING CARE HOME	FACILITY NUMBER: 019200946
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2022

Type A

Section Cited

CCR

87309(a)

(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
1 2 3 4	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: 04/29/2022
	Plan of Correction
1 2 3 4	Licensee has agreed to put a new lock under the kitchen sink and will submit picture proof to CCLD by POC date.

Type A

Section Cited

CCR

87468.1(a)(6)

Personal Rights of Residents in All Facilities (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. 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 a lock on the side gate and a rod to block the resident's door which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Staff removed the lock and the rod during inspection. Licensee has agreed to conduct a training with all staff about locking exit doors. Licensee will submit sign in sheet to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022

Document Has Been Signed on 04/28/2022 03:40 PM - It Cannot Be Edited

FACILITY NAME: MAMA'S LOVING CARE HOME	FACILITY NUMBER: 019200946
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2022

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not completing health screening and TB test for S1 which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/13/2022
	Plan of Correction
1 2 3 4	Licensee has agreed to obtain health screening and TB test for S1. Licensee will submit a copy to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022

FACILITY NAME: MAMA'S LOVING CARE HOME	FACILITY NUMBER: 019200946
	VISIT DATE: 04/28/2022

FACILITY NAME: MAMA'S LOVING CARE HOME	FACILITY NUMBER: 019200946
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2022

Type B

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance (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) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not associating S1 to the facility which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/02/2022
	Plan of Correction
1 2 3 4	Licensee has agreed to associate S1 to the facility and submit documentation to CCLD by POC date.

Type B

Section Cited

CCR

87405(a)

Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above by not having administrator at the facility for sufficient number of hours which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/06/2022
	Plan of Correction
1 2 3 4	Licensee has agreed to submit a plan for administrator or assistant administrator to be at the facility for at least 20 hours a week to oversee facility operations. Licensee will submit the plan to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022