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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 07:28:58 PM

Document Has Been Signed on 09/29/2023 07:28 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 - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eunice O'Farrell, Assistant Executive Director
Narcisa Gordillo, Memory Care Director		TIME COMPLETED:
07:30 PM
NARRATIVE
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On 9/29/2023 at 2:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Assistant Executive Director, Eunice O'Farrell and explained the purpose of the visit.

During visit, LPA reviewed staff training and observed staff completed training which includes dementia, food service, resident rights, medication, hospice, ADL (Activities of Daily Living) care, and other topics. LPA interviewed 2 residents and 2 staff starting at 4:00PM. At around 5:30PM, LPA reviewed a sample of resident's medications.

At 3:30PM, LPA observed facility does not have home health written agreement for a resident.

At 6:00PM, LPA observed R4's doctor's order dated 4/11/2023 stated R4 is taking Acetaminophen 1000mg. However, LPA observed facility has a bottle of Acetaminophen 325mg. R4 also has a bottle of Acetaminophen 500mg. Facility has faxed R4's doctor the medication clarification/request and provided a copy to LPA 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. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
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 07:28 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Grace Luk On 09/29/2023 at 06:29 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: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type B
Section Cited
CCR
87609(b)(4)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above not having a home health agency written agreement which poses a potential health and safety risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Facility has agreed to obtain the home health agency written agreement and submit a copy to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 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)
Page: 2 of 4
Document Has Been Signed on 09/29/2023 07:28 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Grace Luk On 09/29/2023 at 06:38 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: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having a bottle of Acetaminophen 325mg when doctor's order was for Acetaminophen 1000mg which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/30/2023
Plan of Correction
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Facility currently has another bottle of Acetaminophen 500mg. Facility has faxed R4's doctor the medication clarification/request and provided a copy to LPA during inspection. Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 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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