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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201039
Report Date: 07/28/2022
Date Signed: 07/28/2022 04:10:39 PM


Document Has Been Signed on 07/28/2022 04:10 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:CAREFIELD PLEASANTONFACILITY NUMBER:
019201039
ADMINISTRATOR:SINGH, PARVEENFACILITY TYPE:
740
ADDRESS:4115 MOHR AVE.TELEPHONE:
(925) 461-8409
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:82CENSUS: 44DATE:
07/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Parveen Singh, Senior Executive Director
Jocelyn Sanjuan, Business Office Director		TIME COMPLETED:
02:30 PM
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On 7/28/2022 at 12:55PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 7/26/2022. LPA met with Business Office Director, Jocelyn Sanjuan. Senior Executive Director, Parveen Singh arrived a couple hours later.

Death report dated 7/26/2022 stated that R1 was found unresponsive on 7/22/2022 and staff called paramedics. R1 has a DNR on file. R1 passed away at the facility on 7/22/2022.

During visit, LPA reviewed R1's file and observed physician's report dated 7/15/2022 stated that R1's primary diagnosis was Cerebral Infarction affecting right dominant side, Dysphagia, and CHF. R1's secondary diagnosis was Chronic Kidney Disease and Vascular Dementia. Facility notes indicated that R1 did not eat much for a couple days prior to passing. Interview with staff indicated that R1 did not eat much prior to moving into the facility. Paramedics pronounced death on 7/22/2022.


No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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