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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201108
Report Date: 05/31/2022
Date Signed: 05/31/2022 02:59:59 PM


Document Has Been Signed on 05/31/2022 02:59 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:HEALTHY LIVING RESIDENTIAL CARE, INC.FACILITY NUMBER:
019201108
ADMINISTRATOR:BOOKER, JOSEFINAFACILITY TYPE:
740
ADDRESS:1179 VIA LUCASTELEPHONE:
(510) 397-0326
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:6CENSUS: 6DATE:
05/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:JOSEFINA BOOKER, AdministratorTIME COMPLETED:
03:10 PM
NARRATIVE
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On 5/31/22 at 12:41PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit for different purpose. LPA met with administrator Josefina Booker and explained the purpose of the visit.


THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· Approximately 12:50 p.m., LPA observed 2 centrally stored medication cabinet were unlocked. Staff stated that they would be locked at night time. Administrator locked them up during visit.
· Approximately 12:55 p.m., LPA observed unlocked knives in a kitchen drawer, and cleaning supplies in kitchen cabinets under the sink. Padlocks were hung on the cabinet doors but left unlocked. Administrator locked them up during visit.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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 2


Document Has Been Signed on 05/31/2022 02:59 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: HEALTHY LIVING RESIDENTIAL CARE, INC.
FACILITY NUMBER: 019201108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2022
Section Cited

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87465 Incidental Medical and Dental Care
(h)The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by…
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Based on observation, interview and record review, licensee did not comply with the section cited above. LPA observed medications left on the dinning table, and also the centrally stored medication cabinets were unlocked which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
06/01/2022
Section Cited

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)

This requirement is not met as evidenced by…
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed unlocked knives in kitchen drawer and cleaning supplies in kitchen cabinets under the sink which poses an immediate health, safety or personal rights risk to 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2