<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201107
Report Date: 12/26/2024
Date Signed: 12/26/2024 07:10:46 PM

Document Has Been Signed on 12/26/2024 07:10 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/
DIRECTOR:		CHAND, VIMALFACILITY TYPE:
735
ADDRESS:2326 WESTMINISTERTELEPHONE:
(707) 819-6323
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 5CENSUS: 4DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Vimal Chand, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
07:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/26/2024 at 1:40PM, 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 3 hours later.

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 5/10/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water was measured at 105.8 degrees F in the hallway bathroom. There were adequate lights in each room. First Aid kit is complete. LPA reviewed 4 clients and 2 staff files starting at 3:00PM. LPA reviewed a sample of client's medications. LPA reviewed client's P&I money with log. LPA interviewed 1 client and 1 staff during inspection.

At 2:30PM, LPA observed pool gate was unlocked and the combination lock has the combination taped onto the lock. LPA was able to open the lock with the combination provided which is accessible to clients. Civil penalty of $500 is being assessed.
At 3:45PM, LPA observed C4's file was incomplete.
At 3:50PM, LPA observed C1, C2, and C3 does not have current IPP or appraisal needs and service on file.
At 4:30PM, LPA observed facility did not conduct quarterly disaster drills.
At 5:30PM, LPA observed C3's P&I log was calculated incorrectly.

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

Exit interview conducted. A copy of this report, civil penalty, and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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 6
Document Has Been Signed on 12/26/2024 07:10 PM - It Cannot Be Edited


Created By: Grace Luk On 12/26/2024 at 06:13 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: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(e)
Building and Grounds
(e) All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having pool gate unlocked and accessible to clients which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
1
2
3
4
Adminstrator locked up the pool gate and removed the combination code on the lock during inspection. Defciency cleared.
Civil penalty of $500 is being assessed.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/26/2024 07:10 PM - It Cannot Be Edited


Created By: Grace Luk On 12/26/2024 at 06:13 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: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not conducting disaster drills quarterly which poses a potential health and safety risk to persons in care.
POC Due Date: 01/13/2025
Plan of Correction
1
2
3
4
Administrator has agreed to conduct a disaster drill and submit drill log to CCLD by POC date.
Type B
Section Cited
CCR
80026(h)(1)
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:
(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not having accurate ledger for C3's P&I log which poses a potential personal rights risk to persons in care.
POC Due Date: 01/13/2025
Plan of Correction
1
2
3
4
Administrator has agreed to re-calculate C3's P&I money and update P&I log accordingly. Administrator will submit new log 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: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/26/2024 07:10 PM - It Cannot Be Edited


Created By: Grace Luk On 12/26/2024 at 06:45 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: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by having C4's file incomplete which poses a potential health and safety risk to persons in care.
POC Due Date: 01/13/2025
Plan of Correction
1
2
3
4
Administrator has agreed to update C4's file and make sure C4's file is ready for review by POC date. Administrator will submit self-certification to CCLD by POC date.
Type B
Section Cited
CCR
80068.2(b)(1)
(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:
(1) The needs appraisal or IPP is not more than one year old.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having current IPP or appraisal needs and service plan which poses a potential health and safety risk to persons in care.
POC Due Date: 01/13/2025
Plan of Correction
1
2
3
4
Administrator has agreed to obtain current IPP or needs and service plan (LIC625). Administrator will submit the documents 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: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 6 of 6