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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201039
Report Date: 09/29/2023
Date Signed: 09/29/2023 07:26:29 PM


Document Has Been Signed on 09/29/2023 07:26 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: 38DATE:
09/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eunice O'Farrell, Assistant Executive DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
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On 9/29/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Assistant Executive Director, Eunice O'Farrell.

During the course of investigation for complaint (#15-AS-20221229131014), the following deficiency was observed.

Interview with staff (S2) revealed that facility did not always submit an incident report for R1's falls. LPA observed only 3 incident reports regarding R1's fall. However, R1 had other falls that was not reported to CCLD.

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

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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 09/29/2023 07:26 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: CAREFIELD PLEASANTON
FACILITY NUMBER: 019201039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
87211(a)(1)

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Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified... This requirement is not met as evidence by:
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Facility has agreed to conduct a training regarding reporting requirements. Facility will submit staff sign in sheet and training materials to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not reporting all of R1's falls 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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