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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201107
Report Date: 12/03/2021
Date Signed: 12/03/2021 12:11:28 PM

Document Has Been Signed on 12/03/2021 12:11 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:LIBBIE CARE HOME 2FACILITY NUMBER:
019201107
ADMINISTRATOR:CHAND, VIMALFACILITY TYPE:
735
ADDRESS:2236 WESTMINISTERTELEPHONE:
(707) 819-6323
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 5CENSUS: 0DATE:
12/03/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Vimal Chand, LicenseeTIME COMPLETED:
12:20 PM
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On 12/3/2021 at 8:55AM, Licensing Program Analysts (LPAs) G. Luk and J. Clancy-Czuleger arrived to conduct a Pre-Licensing inspection. LPAs met with Licensee, Vimal Chand. The facility's fire clearance was approved for 5 ambulatory clients.

LPAs toured facility including but not limited to client's bedrooms, bathrooms, living room, kitchen, garage, and outdoor area. Client's rooms were fully furnished and clean. LPAs observed lighting in all rooms. LPAs observed facility had some non-perishable and perishable food supply. Licensee will purchase additional food supplies once facility is licensed. Smoke detectors and carbon monoxide detector were observed in operating condition. First aid kit was complete. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full and last serviced on 2/19/2021. Emergency disaster plan was complete.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. Hot water was measured at 134 degrees F. LPAs observed that the water heater making an unusual sound. LPAs advised licensee to look into repair or replacing the water heater to ensure hot water is between 105 to 120 degrees F .

2. LPAs observed pool does not have a pool cover or a 5 ft fence around the pool. Licensee stated that a 5 ft fence will be put in soon.

3. LPAs observed bedroom 3 closet is missing the crawl space cover on the floor.

4. LPAs observed staff room is missing a switch cover by the door.

5. LPAs were informed that a phone line have not been installed.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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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: LIBBIE CARE HOME 2
FACILITY NUMBER: 019201107
VISIT DATE: 12/03/2021
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6. LPAs were informed that the medication cabinet will be located in the cabinet next to the refrigerator and currently does not have a lock. Licensee will put a lock on that cabinet.
7. LPAs observed the side gate on the left side of the house could be used as a second entry point to the pool. Licensee will have the side gate changed to a fixed fence to prevent the second access to the pool. Facility still have another side gate to use as an exit.
8. LPAs observed the fixture above the kitchen sink is not attached to the ceiling and is hanging by the electrical wire.
9. LPAs observed one of the smoke detectors in the living room is missing and wires were exposed.
10. LPAs observed facility does not have the following postings on the walls including: CCLD poster, personal rights, visiting policy, and admission agreement.
11. Facility did not have the following documents at the facility including: plan of operation, facility menu, emergency disaster plan (9 pages), and contingency plan for other natural disasters.

Licensee/applicant will submit proof of corrections to CCL on/before 12/27/2021.

LPAs conducted Component III with Licensee during inspection. LPAs presented Component III Power Point and discussed the regulations embodied in the presentation.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC809 (FAS) - (06/04)
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