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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201138
Report Date: 04/16/2024
Date Signed: 04/16/2024 06:38:33 PM

Document Has Been Signed on 04/16/2024 06:38 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:ASSISTED GRACEFUL LIVINGFACILITY NUMBER:
019201138
ADMINISTRATOR/
DIRECTOR:		KHATU, MANALI SUHASFACILITY TYPE:
740
ADDRESS:3864 PRINCETON WAYTELEPHONE:
(650) 440-9797
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 5DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Manali Khatu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:50 PM
NARRATIVE
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On 4/16/2024 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Maria Zavala and explained the purpose of the visit. Administrator, Manali Khatu arrived an hour later.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, and outdoor area. Smoke and carbon monoxide combination detectors were observed. Fire extinguishers were observed to be full. One week supply of nonperishable and 2-day supply of perishable foods were available. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. The facility has a written emergency disaster plan.

LPA reviewed 5 residents and 3 staff files starting at 11:30AM. LPA interviewed 2 residents and 2 staff. LPA reviewed a sample of resident's medications starting at 4:30PM.

At 10:15AM, LPA observed unlocked cleaning supplies under kitchen sink and bathroom sink. Staff locked up all the items during inspection.

At 10:30AM, LPA observed medication cabinet was unlocked and unlocked medications in the refrigerator. Staff locked up the medications during inspection.

At 11:00AM, LPA measured hot water temperature at 138.5 degrees F in the hallway bathroom. Administrator lowered hot water and LPA re-measured hot water at 120 degrees F.
(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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 8
Document Has Been Signed on 04/16/2024 06:38 PM - It Cannot Be Edited


Created By: Grace Luk On 04/16/2024 at 04:54 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: ASSISTED GRACEFUL LIVING
FACILITY NUMBER: 019201138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 hot water at 138.5 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator lowered hot water and LPA re-measured hot water at 120 degrees F.

Deficiency cleared. Civil penalty of $250 is being assessed for repeat violation.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 unlocked cleaning supplies under the kitchen and bathroom sinks which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Staff locked up the cleaning supplies during inspection.

Deficiency cleared. Civil penalty of $250 is being assessed for repeat violation.
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: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/16/2024 06:38 PM - It Cannot Be Edited


Created By: Grace Luk On 04/16/2024 at 04:54 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: ASSISTED GRACEFUL LIVING
FACILITY NUMBER: 019201138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 no having health screen and TB test for staff which poses a potential health and safety risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator has agreed to obtain health screening for S2 and S3. Administrator will also obtain S3's TB test and submit all 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: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/16/2024 06:38 PM - It Cannot Be Edited


Created By: Grace Luk On 04/16/2024 at 04:54 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: ASSISTED GRACEFUL LIVING
FACILITY NUMBER: 019201138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not obtaining permit prior to alteration which poses a potential health and safety risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator has agreed to contact the City regarding permit for altering the window to an exit door and sumbit communication to CCLD by POC date.
Type B
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

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 non-ambulatory residents in an ambulatory room which poses a potential health and safety risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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Administrator has agreed to submit a new sketch with ambulatory status in each room and LIC200 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: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


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: ASSISTED GRACEFUL LIVING
FACILITY NUMBER: 019201138
VISIT DATE: 04/16/2024
NARRATIVE
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At 11:10AM, LPA observed uncleared staff (S5) at the facility. LPA was informed that S5 is a housekeeper. During visit, LPA observed S5 was sitting in the dining table with residents. S5 left the facility during inspection.

At 12:00PM, LPA observed S2 and S3 does not have health screening. S3 does not have TB test results.

At 12:20PM, LPA observed two non-ambulatory residents in room 5. However, room 5 was approved for ambulatory resident only. LPA observed room 5 has an exit door that was installed recently.

At 12:30PM, LPA observed room 5's window was altered to an exit door. LPA was informed that the alteration occurred in October or November of 2023 and currently waiting for retro-permit.

Civil penalties are being assessed for repeat violations and caregiver background check.

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, civil penalty, and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 04/16/2024 06:38 PM - It Cannot Be Edited


Created By: Grace Luk On 04/16/2024 at 05:39 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: ASSISTED GRACEFUL LIVING
FACILITY NUMBER: 019201138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the cabinet and refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Staff locked up the medications during inspection.

Deficiency cleared. Civil penalty of $250 is being assessed for repeat violation.
Type A
Section Cited
CCR
87355(e)(1)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
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 uncleared staff at the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Staff (S5) left the facility during inspection. Administrator stated that S5 will not be returning to the facility and will submit written statement to CCLD by POC date. Civil penalty of $100 is being assessed.
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: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
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