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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201039
Report Date: 01/24/2025
Date Signed: 01/24/2025 04:31:07 PM

Document Has Been Signed on 01/24/2025 04:31 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/
DIRECTOR:		O'FARRELL, EUNICEFACILITY TYPE:
740
ADDRESS:4115 MOHR AVE.TELEPHONE:
(925) 461-8409
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY: 82CENSUS: 49DATE:
01/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Eunice O'Farrell, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 1/24/2025 at 2:25PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 1/23/2025. LPA met with Executive Director, Eunice O'Farrell and informed her the reason for the visit.

Based on the incident report received on 1/23/2025, med tech noticed that R1 was not in his room and was not able to be located during safety status check around 7:20PM on 1/16/2025. The door located in the back parking lot was left propped open while a vendor was bringing in their equipment. Police department was notified and R1 was located by police. R1 was transported back to the facility by R1's family/POA.


During visit, LPA interviewed staff and reviewed R1's file including physician's report, service plan, care notes, and incident report. R1's physician's report stated that R1 cannot leave the facility unassisted.


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

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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 01/24/2025 04:31 PM - It Cannot Be Edited


Created By: Grace Luk On 01/24/2025 at 03:56 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: CAREFIELD PLEASANTON
FACILITY NUMBER: 019201039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2025
Section Cited
CCR
87705(e)(7)

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Care of Persons with Dementia. Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents...
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Executive Director (ED) has agreed to create a plan to address situations when exit door is propped open. ED will submit a copy of the plan to CCLD by POC date.
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This requirement is not met as evidence by: Based on interview and record review, licensee did not comply with the section cited above by having a resident leaving the facility unassisted 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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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