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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201107
Report Date: 12/14/2023
Date Signed: 12/14/2023 03:54:07 PM

Document Has Been Signed on 12/14/2023 03:54 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:2326 WESTMINISTERTELEPHONE:
(707) 819-6323
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 5CENSUS: 3DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Vimal Chand, Administrator/LicenseeTIME COMPLETED:
04:10 PM
NARRATIVE
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On 12/14/2023 at 10:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with staff, Mohini Lata and explained the purpose of the visit. Administrator/Licensee, Vimal Chand arrived 30 minutes later. The facility’s fire clearance was approved for 5 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 5/3/2023. One week of nonperishable and 2-day of perishable food supplies were available. There were adequate lights in each room. First Aid kit is complete. Last fire drill was conducted on 11/19/2023.

LPA reviewed 3 client and 3 staff files starting at 11:30AM. LPA reviewed a sample of client's medications starting at 2:00PM. LPA interviewed 2 clients and 1 staff at around 2:30PM.

At 10:35AM, LPA observed unlocked knife in the kitchen drawer. Staff locked up knife during inspection.

At 11:00AM, LPA measured hot water temperature was measured at 138.5 degrees F in the bathroom sink.

At 12:40PM, LPA observed S2 does not have chest x-ray results on file.

At 1:30PM, LPA observed facility did not have a disaster & mass casualty plan on file.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.
Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 12/14/2023 03:54 PM - It Cannot Be Edited


Created By: Grace Luk On 12/14/2023 at 02:42 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: LIBBIE CARE HOME 2
FACILITY NUMBER: 019201107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having knife accessible which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Staff locked up the knife during inspection.

Deficiency cleared.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having hot water temperature at 138.5 F which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator has agreed to lower the hot water temperature and submit picture proof to CCLD by POC date.
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: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/14/2023 03:54 PM - It Cannot Be Edited


Created By: Grace Luk On 12/14/2023 at 02:42 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: LIBBIE CARE HOME 2
FACILITY NUMBER: 019201107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

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 by not having chest x-ray results for S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Administrator has agreed to obtain chest x-ray results for S2 and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

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 by not having disaster & mass casualty plan on file which poses a potential health and safety risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Administrator has agreed to obtain the disaster & mass casualty plan and submit a copy to CCLD by POC date.
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: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
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